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ESSAYS 

IN 

SURGICAL  ANATOMY  AND  SURGERY, 


AN  ESSAY  UPON  T[TE  SURGICAL  ANATOMY  ANT)  JTISTORY 

OF  THE  COMMON,  EXTERNAL,  AND  INTEP.NAL 

CAROTID  ARTERIES. 

AWARDEJ)  THE  FiRST  PkIZE  OF  THE  AMERICAN  MeOICA^  AsHOCIATrON, 

June,  1878. 


AN  ESSAY  UPON  THE  SURGICAL  ANATOMY  AND  HISTORY 

OF  THE  INNOMINATE  AND  SUBCLAVIAN 

ARTERIES. 

Awarded  the  Second  Prize  of  the  American  Medical  As.sociation, 

June,  1878. 


AN  ESSAY  UPON  THE  SURGICAL  ANATOMY  OF  THE 
TIBIO-'l'ARSAL  REGION. 

Awarded  the  (James  R.  Wood)  Annual  Prize  of  the  Alumni  Association 
OF  the  Bellevue  Hospital  Medical  College,  1876. 


AN  ESSAY  UPON  THE  SURGICAL  ANATOMY  OF  THE 

OBTURATOR  ARTERY,  AND  NOTES  UPON 

THE  SURGICAL  ANATOMY  OF 

THE  HIP-JOINT. 


BY 

JOHN  A.  YVYETH,  M.D., 

(university  of  LOUISVILLE,) 

Menilier  of  the  New  York  County  Medical  Society,  the  New  York  Pathological  Society  ; 

Honorary  Member  of  the  College  of  Physicians  and  Surgeons 

of  Little  Rock,  Arkansas. 


NEW    YORK: 
WILLIAM  WOOD  &  CO.,  Publishers, 

27  Great  Jones  Street. 
1879. 


PHILADELPHIA  : 
COLLINS,     PRINTER, 

705  Jayne  Street. 


REPORT  OF  THE  COMMITTEE  ON  PRIZE  ESSAYS. 


Your  Comtnittee  to  determine  the  merits  of  prize  essays  would 
respectfully  report:  That  they  have  had  three  separate  papers  sub- 
mitted to  their  inspection.  Two  of  these  papers  present  subjects  of 
very  great  interest  and  show  original  researclies,  but  are  too  imper- 
fect in  the  estimation  of  the  Committee  to  command  a  prize.  The 
remaining  paper,  in  the  judgment  of  your  Committee,  is  fully  up  to 
the  requirements.  Indeed,  the  paper  is  so  elaborate  as  to  fill  a  large 
space  in  the  volume  of  the  Transactions  of  the  Association.  The 
paper  should  be  considered  as  two^  and  not  as  one.  The  analysis  of 
789  cases  of  operation  on  tlje  carotid  artery,  and  the  careful  and 
minute  measurements  of  the  artery  and  its  branches  in  121  subjects, 
showing  the  range  of  variation  and  the  percentage  of  the  same,  fol- 
lowed by  inferences,  bold  and  original,  naturally  constitutes  a  paper 
complete  in  itself  Another  one  on  the  same  plan  with  reference  to 
the  innominate  and  subclavian,  being  an  analysis  of  300  cases,  and 
the  observation  of  52  subjects,  is  presented  to  us  in  such  a  manner 
that  we  may  consider  the  whole  as  one  prize,  or  they  may  compete 
for  both. 

Your  Committee  believe  that  both  prizes  should  be  awarded  to 
the  two  essays  by  one  person.  The  motto  is  '■'■Teynpora  muiantur  et 
nosmuiamur  m  illisJ'' 

B.  M.  MOORE,  Chairman. 
THOS.  LOTHROP, 
H.  R.  HOPKINS, 
W.  W.  MINER. 

Buffalo,  N.  Y.,  June  6,  1878. 


HIS  FRIEND, 

S.  S.  LAWS,  A.M.,  D.D.,  LL.D.,  M.D., 

PRESIDENT  OF  THE  MISSOURI  STATE  UNIVERSITY, 

THE  AUTHOR 

BEGS   LEAVE    TO    INSCRIBE 


%\im  €mp. 


PREFACE. 


I  HAVE  been  encouraged  to  offer  to  the  profession,  in  a  complete 
volume,  these  "Essays  on  Surgical  Anatomy  and  Surgery,"  since 
separately  they  have  been  received  with  such  marked  favor  by  gen- 
tlemen eminently  qualified  to  judge  of  their  respective  merits.  It 
is  gratifying  to  know  that  they  have  already  been  accepted  as  stand- 
ard contributions  to  surgical  and  anatomical  literature,  and  that  the 
conclusions  arrived  at  are  taught  in  the  lecture-rooms  of  some  of 
our  leading  medical  colleges.  Three  of  these  essays  (and  only  three) 
were  offered  in  competition  for  prizes  given  by  liberal  associations, 
and  in  each  instance  with  gratifying  success.  I  am  under  lasting 
obligations  to  the  Committee  on  Publication  of  the  American  Med- 
ical Association,  and  to  the  Alumni  Association  Prize  Committee 
for  the  privilege  of  publishing  these  Essays  in  other  than  their 
original  form. 

The  dissections  embodied  in  these  Essays  were  made  in  every 
instance  by  myself,  and  the  measurements  were  noted  at  the  time. 
The  deductions  are  positive.  No  less  positive  the  conviction,  that 
"  Surgical  Anatomy"  has  not  heretofore,  nor  does  it  now  receive 
that  careful  consideration  its  vast  importance  demands.  Plow  few 
graduates  of  American  colleges,  who  either  practice  surgery  or  put 
themselves  in  a  position  where  an  emergency  may  require  them  to 
undertake  a  dangerous  surgical  procedure,  are  equal  to  the  occa- 
sion !  While  it  is  true  that  for  the  majority  of  operations  the  prac- 
titioner has  time  and  may  make  the  opportunity  to  prepare  himself 
for  any  given  case,  by  special  dissections,  yet  the  time  does  come 
to  all  when  instant  and  decisive  action  is  required;  when  the  pa- 
tient's life,  dependent  upon  his  skill  and  that  self-possession  which 
comes  from  a  consciousness  of  careful  preparation,  hangs  by  such  a 
slender  thread  that  one  mistake  alone  is  fatal.  Is  it  not  close  to  the 
border-land  of  criminality  to  place  one's  self  in  this  position? 

And  yet  I  have  heard  teachers  in  great  American  colleges  say 
that  "too  much  anatomy  was  dangerous,"  and  have  heard  it  instilled 
into  the  minds  of  students  that  it  was  a  good  maxim,  "to  cut  when  it 

(V) 


VI  PREFACE. 

was  necessary,  and  tie  what  was  cut."  From  such  teachings  has  sprang 
the  lack  of  preparation,  and  from  both,  the  reckless  practice  which 
is  called  Surgery;  a  practice  which  would  ligature  a  large  artery 
for  a  lesion'  involving  an  insignificant  branch,  the  former  easily 
performed  and  dangerous  in  its  results,  the  latter  more  difficult  but 
trifling  in  its  consequences. 

In  the  winter  of  1876,  in  some  statements  made  before  the  ISTew 
York  County  Medical  Society,  upon  the  subject  of  one  of  these 
Essays  upon  which  I  was  then  engaged,  I  earnestly  censured  the 
practice  of  tying  the  commori  carotid  for  any  lesion  of  the  external 
carotid  or  its  branches,  when  there  was  one-half  an  inch  between 
the  lesion  and  the  bifurcation  of  the  primitive  trunh.  My  conclu- 
sions met  with  the  approval  of  two  eminent  surgeons,  themselves 
Professors  of  Surgical  Anatomy  in  the  College  of  Physicians  and 
Surgeons  and  the  Bellevue  Hospital  College,  and  within  the  last 
year  several  younger  American  surgeons  have  with  creditable  skill 
ligatured  the  branches  of  the  external  carotid^  rather  than  tie  the 
common  trunk}  These  few  instances,  with  those  gathered  in  these 
pages,  will,  I  hope,  inaugurate  a  new  era  in  the  operative  surgery 
of  the  neck,  and  will  furthermore  encourage  younger  men  not  to 
accept  any  procedure,  no  matter  how  high  the  authority  which  en- 
dorses it,  unless  it  stands  the  test  of  a  critical  analysis. 

In  gleaning  from  the  almost  boundless  field  of  professional  litera- 
ture the  "Surgical  Histories  of  the  Great  Vessels  of  the  Neck,"  it 
has  been  my  aim  to  arrive  at  the  truth,  positive  and  indisputable. 
I  have  accepted  nothing  that  was  not  satisfactorily  stated,  not  wish- 
ing to  swell  the  manuscript  with  irrelevant  matter.  To  this  end  I 
have  omitted  several  hundred  cases  of  deligation  of  these  vessels, 
heretofore  published  ;  those  of  the  subclavian^  artery  when  from  the 
description  of  the  operation  I  was  satisfied  that  the  axillary  was  the 
vessel  tied ;  those  of  the  other  vessels  when  the  results  were  not 
given,  or  the  operation  couched  in  uncertain  terms. 

Besides  the  published  cases  I  have  been  fortunate  in  obtaining 
many  operations  from  private  sources  in  answer  to  a  circular  letter 
of  inquiry  sent  to  every  quarter  of  the  civilized  world.  To  each  of 
these  gentlemen  who  so  courteously  responded  I  beg  to  express  my 

'  Prof.  Jos.  W.  Howe  has  recently  tied  both  lingual  arteries  below  the  posterior 
belly  of  the  digastric.  Dr.  George  F.  Shrady  performed  the  same  operation  upon 
the  lingual  of  one  side.  Prof.  L.  A.  Stimson  tied  both  Unguals  above  the  hyoid 
bone  behind  the  hyo-glossus. 

2  The  subclavian  is  considered  as  terminating  at  the  lower  border  of  the  first  rib. 


PREFACE,  Vll 

obligations  for  the  generous  contributions  to  the  success  of  my  un- 
dertaking. My  thanks  are  especially  due  to  my  friend,  the  late 
Professor  Alpheus  B.  Crosby,  and  to  Professor  Edward  G.  Jane- 
way,  for  the  use  of  dissecting  material  under  their  control,  which 
would  with  difficulty  have  been  obtained  elsewhere,  and  without 
which  my  investigations  could  not  have  been  so  fully  completed 
I  beg  to  acknowledge  my  obligations  to  the  Society  of  the  New 
York  Hospital  for  the  use  of  their  magnificent  library,  and  to  the 
many  courtesies  extended  to  me  by  Dr.  Vandervoort  and  son,  the 
librarians ;  to  the  New  York  Medical  Journal  Association,  and  to 
Professor  A.  B,  Mott  for  the  use  of  the  private  notes  of  operations 
by  his  distinguished  father. 

I  have  received  valuable  assistance  from  the  following  works : 
"Contributions  to  Practical  Surgery,"^  by  Dr.  George  W.  Norris, 
of  Philadelphia;  an  admirable  article  by  Dr.  Ch.  Pilz,  "Zur  Liga- 
tur  der  Arteria  Carotis  Communis;"^  "Ligature  of  the  Common 
Carotid,"  by  Prof.  Jas.  R.  Wood  ;3  "Des  Bffets  Produits  sur  I'En- 
cdphale,"  etc.,  by  Dr.  J.  Ehrmann  ;■*  a  "  Prize  Thesis  on  Ligature  of 
the  External  Carotid  Artery,"^  by  Dr.  Landon  E.  Longworth  ;  "Zur 
Ligatur  der  Arteria  Carotis  Externa,"®  by  Dr.  Madelung;  "Medical 
and  Surgicar History  of  the  War,"  by  Dr.  Geo.  A.  Otis,  U.S.A.; 
"Ligature  of  the  Subclavian  Artery,"''  by  Prof.  Willard  Parker; 
"Ueber  Unterbindungen  und  Aneurysmen  der  Arteria  Subclavia,"- 
by  Wilhelm  Koch;  and  to  a  magnificent  paper  on  "Subclavian 
Aneurism,"^  by  the  lamented  Alfred  Poland. 

These  various  publications  I  have  used  for  reference  to  the  origi- 
nal article,  which  I  have  consulted  when  it  was  available;  when 
not  available  I  copied  directly  from  the  article  accredited.  I  am 
indebted  to  my  pupils,  Drs.  W.  L.  Wardwell  and  M.  C.  Wyeth,  for 
much  valuable  assistance  in  reviewing  the  voluminous  manuscript. 
It  is  impossible  not  to  be  attracted  by  the  startling  mortality 
following  these  capital  operations  upon  the  common  carotid^  innowi- 
naie  and  subclavian  arteries;  operations  which  have  been  and  are 
now  taught  and  practised  as  justifiable  procedures  by  many  eminent 
men.     And  are  we  not  justified  in  believing  that  this  death-rate 

'  Lindsay  &  Blakistoii,  Philadelpliia,  1873. 

2  Archiv  fiir  Klinisclie  Cliirurgie,  186S. 

3  New  York  Medical  Journal,  1856,  *■  J.  B.  Bailliere,  Paris,  1860. 

6  G.  P.  Putnam's  Sons,  New  York,  1873.       6  Archiv  fur  Klinische  Cbinirgie. 

1  New  York  Medical  Record.  8  Archiv  fiir  Klinische  Chirurgie,  1869. 

*  Guy's  Hospital  Reports,  London. 


VIU  PREFACE. 

would  be  shown  to  be  still  greater  if  all  of  the  unsuccessful  cases 
were  made  public;  if  every  surgeon  was  honest  enough  to  acknow- 
ledge publicly  his  failures  as  we  are  all  willing  to  herald  our  suc- 
cesses ? 

In  the  Essay  upon  the  Surgical  Anatomy  and  History  of  the 
Carotid  Arteries,  I  claim  to  prove  that  ligature  of  the  common  caro- 
tid for  a  lesion  of  the  external  carotid  or  its  branches,  when  there  is 
half  an  inch  between  the  seat  of  lesion  and  the  origin  of  the  ex- 
ternal carotid^  is  wrong  in  principle^  unsafe  in  practice^  and  should 
cease  to  he  a  s^irgical procedure.  The  deligation  of  the  common  caro- 
tid is  and  has  been  the  almost  universal  teaching  and  practice,  the 
objections  to  tying  \\\e  external  being  that  the  origins  of  the  branches 
of  this  artery  were  usually  so  close  together  and  so  irregular  in 
their  relations  (the  anatomical  objection),  while  the  danger  of 
hemorrhage  was  the  clinical  objection. 

I  have  proven,  in  the  analysis  of  one  hundred  and  twenty-one 
consecutive  and  carefully  measured  dissections  of  the  three  caro^i'c^s, 
that  the  anatomical  objection  has  been  greatly  exaggerated  and 
does  not  contra-indicate  the  ligature  of  the  external  carotid^  while 
the  analysis  of  the  Surgical  Histories  of  these  vessels,  containing 
898  carefully  collected  cases,  shows  the  death-rate  after  ligature  of 
the  common  carotid  to  be  41  per  cent.;  that  of  the  external  carotid  to 
be  only  4|  per  cent.! 

Surgery  as  a  Progressive  Science  must  abandon  any  practice 
which  endangers  human  life,  when  a  safer  method  is  demonstrated. 

I  hold  it  to  be  bad  surgery  which  places  a  ligature  upon  the 
common  carotid  for  a  wound  of  the  internal  carotid  artery. 

The  proper  procedure  is  given  in  the  text.  I  believe  it  to  be 
bad  surgery  which  places  a  ligature  upon  the  common  carotid  for  a 
lesion  of  the  vertebral  artery.  The  method  of  differentiation  is 
demonstrated  in  the  text. 

In  the  Essay  upon  the  "Innominate  and  Subclavian  Arteries,"  I 
claim  to  prove  that  ligature  of  the  arteria  innominata  on  account  of 
aneurism  is  not  a  justifiable  operation,  and  that  ligature  of  the  sub- 
clavian arteries  (more  especially  the  right)  in  their  first  surgical 
divisions  on  account  of  aneurism  is  alike  unjustifiable.  Nature  left 
to  her  own  resources  is  more  successful  than  the  surgery  which  ties 
these  vessels  ;  while  the  methods  which  belong  to  Conservative  Sur- 
gery are  given,  which  are  still  more  successful  in  the  alleviation  of 
sufi'ering  and  the  preservation  of  life. 

The  very  exceptional  conditions  in  which  these  vessels  may  re- 
quire the  ligature  are  mentioned  hereafter. 


IMiEFACE.  IX 

I  believe  that  the  mortality  of  65  per  cent,  following  ligature  of 
the  suhclavian  arteries  in  their  8d  surgical  divisions  on  account  of 
hemorrhage;  and  the  mortality  of  4-3  per  cent,  after  ligature  of 
these  vessels  in  their  8d  divisions  on  account  of  aneurism,  are  un- 
necessarily great,  and  that  the  methods  of  decreasing  this  mortality 
are  demonstrated. 

The  article  on  the  Obturator  Artery  was  originally  published  in 
the  New  York  Medical  Record^  and  those  on  the  Hip  Joint  in  Pro- 
fessor Sayres'  popular  work  on  "Orthopedic  Surgery  and  Diseases 
of  the  Joints." 

The  "Essay  on  the  Surgical  Anatomy  of  the  Tibio-Tarsal  Region" 
was  published  in  the  American  Journal  of  the  Medical  Sciences  in 
1876.  I  discovered  that  the  arterial  distribution  in  this  region  was 
not  correctly  described  by  the  popular  text  books  on  anatomy,  and 
I.  believed  that  the  frequent  surgical  operations  at  the  ankle-joint 
based  upon  a  wrong  idea  of  the  anatomy  were  not  so  safe  as  those 
founded  upon  a  close  and  minute  understanding  of  the  relations  of 
the  vessels  at  this  point.  Subsequent  reflection  has  not  changed 
my  convictions  upon  this  subject. 

In  conclusion,  conscious  that  I  have  labored  earnestly  to  arrive 
at  the  truth;  alike  conscious  that  no  human  undertaking  can  be 
utterly  free  from  error,  I  offer  these  essays  to  the  medical  profession 
without  an  apology,  feeling  assured  that  what  is  worth  enduring  in 
them  will  endure, 

JNO.  A.  WYETH. 

Njew  York,  1878,  44  West  27th  Street. 


THE  SURGICAL  ANATOMY 

OF    THE  . 

COMMON,  INTERNAL,  AND  EXTERNAL  CAROTID 
ARTERIES. 


From  their  exposed  position  in  the  neck,  that  portion  of  the 
human  body  least  protected  from  violence,  the  Carotid  Arteries  and 
their  branches  are  more  often  the  seat  of  lesions  requiring  surgical 
interference  than  any  other  vessels. 

This  clinical  fact,  which  (in  connection  with  their  distribution  to 
the  great  nervous  centre),  makes  them  of  most  vital  interest  to  the 
surgeon,  together  with  the  varying  descriptions  of  these  vessels  by 
different  anatomists,  and  the  frightful  mortality  following  the  deli- 
gation  of  the  common  trunk  to  which  my  attention  was  called  when 
a  student ; — are  among  the  reasons  which  led  me  to  undertake  the 
labor  embodied  in  this  essay. 

THE   COMMON   CAROTIDS. 

Anatomists  agree,  without  exception,  that  the  common  carotid 
arteries  bifurcate  into  the  external  and  internal  carotids,  almost  in- 
variably on  a  level  with  the  notch  between  the  two  alae  of  the 
thyroid  cartilage ;  this  varying  slightly  as  the  head  is  moved  forward 
or  backward.  In  what  is  known  as  the  "  surgical  position"  of  the 
n€ck,  that  is  with  the  shoulders  slightly  elevated  and  the  head 
thrown  back  and  a  little  below  the  axis  of  the  body  in  the  recum- 
bent position,  there  will  be  found  nothing  so  constant  in  the  ana- 
tomy of  the  arteries  as  the  relation  of  the  termination  of  the  common 
carotid  to  the  upper  border  of  the  thyroid  cartilage. 

In  121  instances,  116  bifurcated  at  this  point.  In  four  cases  the 
bifurcation  was  respectively  one-fourth,  one-half,  three-fourths,  and 
one  inch  above  this  line.     In  the  fifth  case  the  internal  carotid  was 


10  PRIZE    ESSAY. 

wanting,  but  the  small  common  trunk  took  the  usual  distribution 
and  relations  of  the  external  carotid} 

Prof.  Hyrtl  states,  that  any  variation  in  the  bifurcation  of  the 
common  carotid  from  the  point  above  given,  will  be  helow  this  line. 
I  cannot  agree  with  him,  since  in  my  cases  all  the  exceptions  were 
ubove  this  point. 

The  anatomy  of  the  common  carotids  is  so  simple,  and  so  much  has 
been  written  concerning  them,  that  I  can  add  nothing  of  importance 
to  the  researches  of  others.  What  there  may  be  of  originality  in 
these  investigations  will  be  found  in  the  tioo  upper  anterior  triangles  ; 
namely,  the  trigonum  colli superius  and  trigonum  submaxillar e.  Taken 
together  they  form  an  irregular  quadrilateral,  the  anterior  limit  of 
which  will  be  the  median  line  of  the  neck,  from  the  symphysis  menti 
to  the  centre  of  the  body  of  the  os  hyoides ;  the  superior  limit  cor- 
responds to  the  lower  margin  of  the  inferior  7naxilla,  along  the  body 
and  ramus  to  the  condyle,  then  backward  and  downward  to  the 
middle  of  the  origin  of  the  sterno-mastoideus  from  the  7nastoid process 
of  the  temporal  bone. 

The  posterior  boundary  will  be  the  median  line  of  the  sterno- 
mastoideus  muscle  down  to  the  point  of  crossing  the  anterior  belly 
of  the  omo-hyoid ;  which  muscle,  passing  upward,  inward,  and  for- 
ward, forms  the  inferior  border  of  this  space.  In  this  quadrilateral^ 
nine-tenths  of  the  surgical  operations,  in  which  the  carotid  arteries  are 
involved,  are  performed.  The  omo-hyoideus  will  be  found  to  cross 
the  common  carotid,  in  the  vast  majority  of  cases,  between  one-and-a- 
half  and  two-and-a-quarter  inches  below  the  bifurcation.  In  a  few 
instances  it  will  be  lower  or  higher  than  this  limit,  owing  to  the 
development  of  the  muscle  or  the  length  of  the  loop  of  deep  cervical 
fascia,  which  passes  from  its  central  tendon  to  the  sternal  extremity 
of  the  first  rib. 

This  irregular  surgical  quadrilateral  is  divided  into  the  two  tri- 
angles above  mentioned  by  a  pair  of  muscles  intimately  associated 

•  lu  the  New  York  Medical  Record,  vol.  xi.  1876,  Dr.  Eugene  Peugnet,  of  Ford- 
ham  Heights,  gives  a  case  very  analogous  to  the  above.  See  also  the  same  case  in 
the  History  of  the  External  Carotid.  Koberweiu  states,  he  had  seen  a  skull  with  only 
one  carotid  canal. 

In  the  case  of  Dr.  Ray  (see  statistics  of  common  carotid  artery),  is  a  notice  of  ano- 
malous absence  of  the  arleria  innominata  ;  the  right  carotid  and  subclavian  coming 
directly  from  the  arch  of  the  aorta. 

I  have  seen  reports  of  one  or  two  cases  in  which  the  external  and  internal  carotids 
on  the  right  side  were  derived  from  the  innominate  at  the  usual  point  of  origin  of  the 
common  trunk. — (  Wien  Med,   Wocli.  No.  96,  p.  1573,  cit.) 


SURGICAL    ANATOMY    OP    CABOTID    ARTERIES.  11 

with  each  other,  viz.,  the  digastricus  (its  posterior  belly),  and  the 
siylo-Jiyoideus.  The  first  of  these  two,  corning  from  the  digastric 
fossa  on  the  under  surface  of  the  niastoid  process,  passes  downward 
and  forward  to  he  attached  by  a  loop  of  Cuscia  to  the  upper  surface 
of  the  hyoid  bone,  the  anterior  belly  being  reflected  upward  and 
forward  to  the  under  surface  of  the  inferior  maxilla  just  outside  the 
symphysis.  The  stylo-liyoideus,  more  deeply  situated  than  the  pre- 
ceding, is  inserted  into  the  os  hyoides  by  two  tendons  whicli  pass  on 
each  side  of  the  central  tendon  of  the  dujastnctis. 

These  two  muscles  vary  considerably  in  their  relation  to  the  origin 
of  the  external  and  internal  carotids,  owing  to  the  varying  distance 
in  different  individuals  between  the  chin  and  the  hyoid  bone.  In 
the  majority  of  ray  dissections  it  crossed  between  one  and  one-and-a- 
half  inches  above  the  bifurcation  of  the  common  carotid.  In  rare 
instances  higher  than  this,  and  in  one  instance  of  a  high  bifurca- 
tion, these  muscles  crossed  at  that  point.  The  stylo- hyoidtus  was 
wanting  in  one  case. 

The  sterno-mastoidetis,  passing  obliquely  downward  and  inward, 
approaches  the  internal  carotid,  occasionally  overlapping  its  outer 
portion,  just  above  its  origin  from  the  common  trunk;  the  anterior 
edge  of  the  muscle  descending  along  the  common  carotid  obliquely 
crosses  to  its  inner  side  completely  overlapping  it,  about  one  inch 
and  a  half  below  the  upper  edge  of  the  thyroid  cartilage. 

It  will  be  noticed  that  the  common  carotid  in  the  last  inch  and  a 
half  of  its  course,  and  both  the  internal  and  external  carotids  in  their 
entire  length,  are  uncovered  by  muscles,  except  the  delicate  platysma 
myoides,  and  the  conjoined  bellies  of  the  stylo-hyoid  and  digastric 
muscles  (about  one-half  an  inc-h  wide),  which  cross  these  last  two 
vessels  from  one  to  one  inch  and  a  half  above  their  origins  from 
the  common  trunk.  A  further  examination  of  the  surgical  anat- 
omy of  these  vessels  will  show  that  in  this  single  triangle,  the 
trigonum  colli  superius,  the  ligature  is  applied  to  the  common  carotid 
in  its  upper  portion,  and  to  the  external  and  internal  carotids  for  all 
lesions  of  these  vessels  not  requiring  a  double  ligature  at  the  seat 
of  injury. 

THE  INTERNAL    CAROTID. 

From  its  direction  this  vessel  seems  to  be  the  direct  continuation 
of  the  main  trunk.  Passing  upward  almost  directly  in  its  first  por- 
tion, it  becomes  slightly  tortuous  as  it  approaches  the  opening  of 
the  carotid  canal.     As  it  leaves  the  common  trunk,  it  is  usually 


12  PRIZE    ESSAY. 

trumpet-shaped;  this  dilatation  being  due,  as  I  think,  to  this  fact; 
the  blood  flowing  forcibly  along  the  main  artery  strikes  the  septum 
of  biFarcation  and  is  deflected  with  a  certain  degree  of  violence  into 
the  two  smaller  carotids.  The  pressure  upon  the  external  is  in- 
stantly relieved  by  its  numerous  branches  of  distribution  derived 
near  its  origin  ;  while  the  internal  is  distended  by  the  constant  pres- 
sure, which  finds  no  relief  until  the  blood  can  travel  through  the 
tortuous  track  of  the  vessel  to  be  distributed  to  the  brain. 

Anatomists,  as  will  be  seen  from  the  extracts  from  various  stand- 
ard works  given  below,  usually  describe  this  artery  as  giving  off  no 
branches.  Sappey  says:  "In  the  course  of  this  vessel  from  its 
origin  to  the  base  of  the  cranium  it  gives  off  no  branches.  Haller 
has,  however,  seen  it  give  off  once  the  ascending  pharyngeal ' and 
another  time  the  occipital.''''^  Gray  says,  "the  cervical  portion  of  the 
internal  carotid  gives  off  no  branches."^  "  The  occipital  has  in  some 
cases  originated  from  the  internal  carotid P  (Quain.^)  Wilson  says, 
"  the  cervical  portion  of  the  internal  carotid  gives  off  no  branches."* 
"In  the  neck  the  internal  carotid  gives  off  no  branches."  (Leidy.^) 
And  Hyrtl,  more  positive  still,  gives  this  artery  as  "invariably 
without  branches."" 

In  120  dissections  in  which  the  internal  carotid  was  present,  the 
ascending  pharyngeal  was  derived  from  it  in  seven.  In  three  of  these 
pharyngeal  arteries  came  from  both  internal  and  external  carotid ; 
in  one  case  there  were  two  branches  from  the  same  internal  carotid. 
I  have  never  seen  the  occipital  from  this  vessel.  All  of  these 
branches  were  derived  within  one  inch  and  a  half  of  the  common 
carotid. 

It  may  be  safely  asserted  that  in  j^ve  per  cent.,  the  internal  carotid 
will  give  off  branches  in  the  first  half  of  its  cervical  portion.  At  the 
same  time,  the  presence  of  these  vessels  offers  no  contra-indication 
to  the  application  of  the  ligature  in  this  region,  since  they  are  so 
small  that  they  will  be  occluded  by  the  inflammatory  adhesions  oc- 
curring at  and  near  the  ligature.  In  the  cases  of  hemorrhage  after 
excision  of  the  tonsils,  given  in  the  accompanying  Surgical  History 
of  the  Common  Carotid,  in  which  this  last  vessel  was  tied  to  arrest 

1  Traite  d'Anatomie  Descriptive,  Paris,  1869. 

2  Anatomy,  Descriptive  aud  Surgical,  London,  1870. 

3  Anatomy  of  the  Human  Body,  London,  1845. 

*  Human  Anatomy,  London,  1858.  ^  Human  Anatomy,  Philadelphia,  1861. 

6  Haudbuch  der  Topographischen  Anatomie,  etc.,  Wien,  1871.  "Die  carotis  in- 
erna  ist  vollkommen  astlos." 


SURGICAL    ANATOMY    OP    CAROTIlJ    ARTERIES.  13 

the  flow  of  blood,  the  lesion  was  in  the  lo7bdllar  bivanches  of  tVie 
ascendiwj  pJiarymjeal.  If  (as  is  advised  in  the  "conclusions"  to  this 
essay),  the  external  carotid  had  been  secured  instead  of  tlie  common^ 
the  hemorrhage  would  not  have  ceased,  and  the  crnarnon  or  internal 
trurdc  would  have  been  necessarily  ligatured.  Notwithstanding  this 
rare  anomalous  derivation  of  these  vessels,  so  great  is  the  difference 
in  the  death-rate  between  the  ligature  of  the  external  and  internal^ 
or  common  carotid  arteries,  that  the  former  should  be  tied  in  all  cases 
without  hesitation.  If  the  hemorrhage  is  not  arrested  the  common 
carotid  may  then  be  tied  at  the  point  of  election. 

THE  EXTERNAL  CAROTID  ARTERY. 

From  the  extensive  distribution  of  its  branches  to  the  exposed 
portions  of  the  neck  and  face,  the  external  carotid  artery  demands  a 
more  careful  consideration  than  any  single  vessel  of  the  human 
body. 

Leaving  the  common  trunk  at  the  upper  border  of  the  thyroid  car- 
tilage, well  forward  of  the  anterior  border  of  the  sterno-mastoid 
muscle,  this  vessel  arches  forwards  and  upwards  (its  concavity 
looking  toward  the  lobule  of  the  ear)  until,  on  an  average  of  .92 
inch  above  the  bifurcation,  after  giving  off  the  facial  branch,  it 
turns  obliquely  upwards  and  backwards  to  a  point  opposite  the  in- 
sertion of  the  external  pterygoid  muscle  into  the  neck  of  the  condyle 
of  the  lower  jaw,  where  it  terminates  by  dividing  into  the  temporal 
and  internal  maxillary  arteries. 

Eight  regular  branches  belong  to  this  vessel  (though  some  anato- 
mists, among  whom  are  Hyrtl,  Wilson,  and  Richardson,  describe 
nine).'  On  its  anterior  aspect  arise  from  below,  upward,  the  thyroidea 
superior,  lingualis,  maxillaris  externa,  and  maxillaris  interna.  On 
its  posterior  and  internal  aspect  the  pharyngea  ascendens,  and  pos- 
teriorly the  occipitalis,  auricularis,  and  temporalis. 

THE   ARTERIA   THYROIDEA   SUPERIOR. 

"  This  vessel  originates  from  the  front  of  the  external  carotid,  just 
above  its  commencement."  (Leidy.^)     "  Close  to  the  external  carotid, 

1  These  writers  give  the  mastoid  branch  of  the  occipital  as  a  branch  of  the  carotid. 
It  will  be  seen  further  on  that  this  occurred  in  only  15  of  120  examinations. 

2  These  extracts  from  celebrated  anatomists  are  given  in  no  spirit  of  criticism  that 
would  reflect  unkindly  or  unjustly  upon  the  reputation  of  these  great  men,  but  to 


14  PEIZE    ESSAY. 

immediately  below  the  cornu  of  the  os  hy aides.''''  (Qnain.)  "From 
the  external  carotid  just  below  the  great  cornu  of  the  hyoid  bone." 
(Grray.)  "Its  origin  is  so  close  to  the  termination  of  the  primitive 
carotid  that  this  last  seems  often  to  terminate  by  a  trifurcation.  It 
is  not  rare  to  see  it  originate  by  a  trunk  common  to  it  and  the 
lingual."  (Sappey.) 

Wilson  gives  the  origin  identical  with  Quain  and  Gray,  while 
Hyrtl  gives  nothing  more  definite  than  that  it  originates  from  the 
commencement  of  the  external  carotid.  The  average  distance  of 
origin  of  the  thyroidea  superior  from  above  the  centre  of  bifurcation 
of  the  common  carotid  (this  being  the  centre  (a  Figs.  1  and  2)  of  a 
triangle,  the  three  sides  of  which  are  drawn,  two  from  the  septum 
of  bifurcation  of  the  two  vessels  downward  to  the  first  swelling  that 
indicates  the  origins  of  the  external  and  internal  carotids  from  the 
primitive  trunk;  the  third  line  or  base  connecting  these  two),  in 
121  cases  (in  all  of  which  it  was  present)  was  .11  inch,  which  point 
is  almost  exactly  opposite  the  septum  between  the  two  vessels. 
(See  Fig.  1.)  By  referring  to  the  lines  radiating  from  T  (see  Fig.  2) 
we  will  have  the  exact  range  or  variation  of  origin  of  this  vessel, 
in  121  cases,  as  deduced  from  the  table  of  measurements.  Between 
a  point  one-eighth  of  an  inch  above,  and  one-sixteenth  of  an  inch 
below  this  centre  already  indicated,  this  vessel  takes  its  origin  in  68 
per  cent.  The  remaining  31  per  cent,  ranged  between  one-eighth 
and  one-half  inch  above  this,  while  1  per  cent,  was  below  the  centre 
of  bifurcation  one-half  inch.  (That  is  in  only  one  single  instance.) 
If  to  this  68  per  cent,  we  add  six  cases  in  which  this  branch  was  de- 
rived one- half  inch  above,  one  case  given  off"  one-half  inch  below 
the  bifurcation,  we  have  over  73  per  cent,  of  cases  in  which,  the 
necessity  existing,  a  ligature  could  be  applied  to  the  external  carotid 
within  one-quarter  of  an  inch  of  its  origin  without  interference  with 
the  thyroidea  superior,  while  a  precautionary  ligature  applied  to  this 
last  vessel  would  render  the  operation  free  from  the  danger  of  se- 
condary hemorrhage,  as  far  as  this  branch  is  concerned. 

In  four  of  121  cases  it  was  from  a  common  trunk  with  other 
branches,  viz.,  twice  in  common  with  the  lingualisy  and  twice  with 

show  that  the  surgical  anatomy  of  this  vef-sel  (the  external  carotid)  has  not  here- 
tofore received  that  careful  and  exact  study  which  its  importance  demands.  In  the 
prominence  it  will  take  in  future  (and  to  which  it  is  hoped  these  labors  may  con- 
tribute to  some  extent),  in  the  department  of  operative  surgery,  it  is  believed  that  a 
more  minute  analysis  of  its  relations  will  be  acceptable  to  the  profession  of  surgery. 


SURGICAL    ANATOMY    OF    CAROTID    ARTERIES.  15 

the  lingvalis  and  maxiUaris  externa  (as  sliown  in  Figs.  5  and  0).  In 
one  case  it  was  from  the  comw.on  carolid  one-half  inch  below  the 
bifurcation. 

Such  is  the  peculiar  position  of  this  artery,  that  should  it  be 
wounded  too  close  to  the  main  trunk  to  allow  of  its  being  tied,  the 
common,  external,  and  internal  carotidi^  would  require  the  li^^ature, 
while  on  account  of  the  free  anastomosis  with  its  fellow  of  the  op- 
posite side,  the  peripheral  end  would  require  torsion.  It  ranks 
fourth  in  size  of  the  branches  of  the  external  carotid,  being  largest  in 
two  of  77  cases  examined  as  to  this  feature.  One  of  the  most  fre- 
quent anomalies  of  the  external  carotid  is  the  origin  of  the  hyoid 
branches  of  the  superior  thyroid  and  lingual  from  the  main  trunk 
between  these  two  vessels. 

Of  its  four  branches  (three  of  which  are  quite  constant),  there  are: 
(1)  The  superior  /orT/w^m?  perforating  the  thyro-hyoid  membrane,  and 
distributing  blood  to  the  muscles  and  mucous  membrane  of  the 
larynx.  Hemorrhage  from  this  artery  has  proved  fatal  in  several 
instances  ;  once  in  an  attempt  to  dislodge  a  fragment  of  oyster-shell 
lodged  beneath  the  epiglottis,  and  again  in  attempts  to  relieve 
oedema  glottidis,  the  hemorrhage  causing  death  by  asphyxia  and  not 
by  exhaustion  proper,  ('i)  The  or ico- thyroid,  wounded  necessarily 
in  the  operation  of  laryngotomy;  and  (3)  the  cervicalis  descendenSy 
which,  crossing  the  sheath  of  the  common  carotid,  superficially  from 
above,  downwards  and  outwards,  is  divided  in  the  operation  of  liga- 
ture of  the  prin^iitive  carotid  above  the  omo-hyoideus.  These  three 
are,  properly  speaking,  the  surgical  branches,  the  hyoid  and  terminal 
thyroid  distribution  possessing  no  special  surgical  interest.  In  two 
instances  1  have  observed  the  thyroidea  siijyerior  turn  abruptly  down 
along  the  sheath  of  the  common  carotid  for  some  distance,  and  then 
turn  sharply  forwards  to  be  distributed  to  the  thyroid  body.  Under 
such  rare  conditions  it  would  probably  be  divided  in  the  incision 
for  ligature  of  the  primitive  carotid  in  the  trigonum  colli  superius.  In 
one  case  of  goitre  this  artery  was  as  large  as  the  external  trunk 
(see  Fig.  8),  seeming  to  be  on  the  order  of  the  "  trifurcation"  spoken 
of  by  Sappey. 

Operation  for  Ligature. — With  the  head  in  the  surgical  position, 
draw  a  line  from  the  base  of  the  tragus  of  the  ear  to  the  sterno- 
clavicular articulation.  Parallel  with  this  line  make  an  incision  an 
inch  or  an  inch  and  a  half  in  length,  the  centre  of  Avhich  shall  be 
opposite  the  upper  border  of  the  thyroid  cartilage.     A  short  incision 


16  PRIZE    ESSAY. 

at  right  angles  to  this,  in  the  direction  of  and  along  the  upper  edge 
of  the  thyroid  cartilage^  will  facilitate  the  operation.  Immediately 
beneath  the  skin  and  platysma  myoides  will  be  seen  the  thyroid^  lin- 
gual^ liyoid  and  other  veins,  which  may  assume  either  of  the  forms 
or  relations  shown  in  Fig.  9,  A  and  B,  being  most  common. 

These  being  tied  and  divided,  or  twisted,  the  artery  will  be  found 
opposite  the  point,  above  so  often  indicated.  In  any  case  it  will  be 
found  within  half  an  inch  above  or  below  this  bifurcation  of  the 
common  carotid  (see  Fig.  2,  T). 

LINGUALIS. 

Gray,  Quain,  Leidy,  and  Hyrtl  agree  in  saying  that  this  artery 
is  derived  opposite  to  and  runs  parallel  with  the  greater  cornu  of 
the  OS  liyoides.  Sappey  gives  it  as  coming  between  the  superior  thy- 
roid ?ca^  facial  sometimes  in  common  with  one  or  the  other.  Wilson 
gives  it  as  "ascending  obliquely  from  its  origin,  and  then  running 
parallel  with  the  cornu  of  the  os  hyoides." 

In  the  121  dissections  tabulated  in  another  portion  of  this  article, 
the  average  distance  of  origin  of  the  lingualis  from  the  centre  of 
bifurcation  (before  given)  was  .68  inch,  from  the  average  of  the 
thyroidea  superior  .57  inch  (see  Fig.  1). 

In  Fig.  2,  the  lines  radiating  from  L  will  give  the  range  of  origin 
of  this  artery  from  the  external  carotid.  In  82  per  cent,  of  cases  this 
vessel  was  derived  from  that  portion  of  the  carotid  between  half  and 
one  inch  above  the  centre  of  bifurcation ;  in  6  per  cent,  between 
one  and  one  and  three-eighth  inches;  in  12  per  cent,  between  half 
and  one-eighth  above.  This  leaves  88  per  cent,  of  cases  in  which 
the  lingualis  is  derived  at  a  sufficient  .distance  above  the  origin  of 
the  external  carotid  to  allow  the  ligature  in  its  first  surgical  division, 
i.e.,  the  portion  below  the  facial,  lingual,  and  occipital. 

While  the  eminent  authorities  above  quoted  generally  agree  in 
regard  to  the  intimate  relation  of  this  vessel  to  the  os  hyoides  (a  re- 
lation which  my  dissections  also  show)  they  do  not  state  anything 
definite  as  to  the  distance  between  it  and  the  thyroidea  superior ;  a 
point  of  no  little  interest,  since  the  ligature  of  the  external  carotid 
in  this,  its  most  important  division,  depends  a  good  deal  upon  the 
average  relation  of  these  two  branches.  In  2  of  121  cases  it  was 
from  a  trunk  common  to  it  and  the  thyroidea  superior ;  in  2  other 
cases  with  this  vessel  and  the  maxillaris  externa  (see  Fig.  6);  in  31 
of  121  cases  it  was  common  with  the  facial ;    making  this  artery 


SURGICAL    ANATOMY    OF    CAROTID    ARTERIES.  17 

abnormally  associated  in  35  of  121,  or  1  in  every  3^-.  In  5  of  77 
cases,  noted  as  to  comparative  size,  this  vessel  was  largest,  making 
it  third  in  size.  Extra  liym'.d  branches  came  from  the  external  cciro- 
</c/ between  the  Ihvjualis  and  tli,yroidea  i^nperior  in  15  of  121  cases. 
Of  its  4  usual  branches  the  liyold^  siiblin(jual^  dorsr.dis  lirujUifi,  and 
ranine^  this  last  is  properly  tlie  surgical  branch.  Its  intimate  relation 
to  the  frse7mm  linguw  often  brings  it  to  the  notice  of  the  surgeon. 

Operation  for  Ligature. — From  its  origin  opposite  the  hyoid  bone 
it  ascends  obliquely  upwards  and  inwards,  and  is  superficial  until  it 
passes  underneath  the  stylo-hyoideus  and  digastricus  {\)OBiQY\OT  belly), 
and  then  more  deeply  behind  the  hyo-glossus  when  it  disappears. 

The  incisions  should  be  made  as  in  the  case  of  the  superior  tliy- 
roid,  except  that  the  centre  o/  the  perpendicular  incision  should  be 
oj)posite  the  as  hyoides  along  which  the  transverse  incision  should  be 
carried.  The  relations  of  the  veins  will  be  as  in  Fig.  9,  and  the 
artery  will  be  found  in  the  lingual  triangle^  bounded  posteriorly  by 
the  external  carotid^  above  by  the  digastric  muscle,  below  by  the  os 
hyoides.  In  82  per  cent,  the  artery  will  be  found  in  the  immediate 
vicinity  of  the  hyoid  bone.  The  middle  constrictor  muscle  is  behind 
it ;  the  platysma  myoides  in  front,  and  under  this  the  veins  above 
noted.  The  hypoglossal  nerve. is  usually  just  above  it  as  it  crosses 
the  carotid,  \fh\\e  the  thyr'o-hyoid  hnxwoh  of  this  nerve  crosses  the 
artery  on  its  way  to  the  muscle  it'supplies.  In  the  accompanying 
history  of  the  common  carotid  this  last  vessel  was  frequently  tied  for 
wounds  of  the  branches  of  the  lingual  in  the  tongue  ;  a  proceeding 
I  cannot  endorse,  for  urgent  reasons  given  in  the  resume  of  the 
Surgical  History. 


MAXILLARIS   EXTERNA   (FACIAL). 

Quain,  Gray,  and  Leidy  give  the  origin  of  this  vessel  as  "just 
above  the  lingual."  Wilson,  as  above  the  hyoid  bone  a  little. 
Sappey  says  "its  origin  superior  to  that  of  the  lingual,  is  very  near 
it;  often  in  common  with  it."  Hyrti  gives  no  definite  origin,  but 
says,  it,  with  the  Imgualis,  is  covered  at  its  origin  by  the  posterior 
belly  of  the  digastric. 

In  my  dissections  it  was  not  the  rule  for  this  muscle  to  cover  the 
lingual  at  its  origin.  In  a  total  of  121  dissections  of  the  external 
carotid,  the  maxillaris  externa  was  present  in  120.  In  the  instance 
2 


18  PRIZE    ESSAY. 

in  which  it  was  missing,  its  place  was  taken  in  its  facial  distribution 
by  the  transverse  facial  from  the  temporal;  in  the  neck,  branches 
from  the  lingual  and  extra  branches  from  the  carotid  to  its  cervical 
distribution-  The  average  distance  of  this  artery  from  the  bifur- 
cation was  .92  inch,  being  .24  inch  removed  from  the  lingualis. 
(See  Fig.  1.)  '  ■ 

The  range  of  its  origin  is  seen  in  Fig.  3,  where  in  65  per  cent, 
the  vessel  was  betv/een  J  and  1  inch,  31  per  cent,  between  1  and 
If,  and  only  4  per  cent,  between  J  and  \  inch  above  the  bifurcation. 
Taking  the  single  case  in  which  this  artery  was  wanting,  and  the 
cases  derived  half  inch  and  above  this  point,  we  have  96  per 
cent,  in  which  ligature  can  be  applied  to  the  first  surgical  division  of 
the  external  carotid  without  danger  from  the  facial  artery.  In  77 
cases  examined  as  .to  comparative  size,  this  branch  was  largest  in  45, 
making  it  the  largest  branch  of  the  external  carotid  artery.  As  shown 
in  Fig.  5,  it  was  common  with  the  lingual  in  its  origin  in  31  of  120 
cases;  with  the  thyroidea  and  lingualis  in  2  cases;  and  with  the 
pharyngea  ascendens  in  1  of  this  number.  In  17  of  120  examina- 
tions, extra  t07isillar  and  pharyngeal  branches  originated  from  the 
carotid  in  connection  with  the  facial. 

Operation  for  Ligature. — In  its  cervical  distribution  this  vessel 
will  require  to  be  tied  at  or  near  its  origin  from  the  carotid.  The 
incision  along  the  axis  of  the  carotid,  as  given  before,  with  its  centre 
a  quarter  of  an  inch  above  the  hyoid  bone,  will  lead  to  the  facial. 
The  relations  of  the  veins  are  shown  in  Fig.  9,  The  posterior  belly 
of  the  digastricus  will  be  found  with  its  centre  usually  above  the 
origin,  but  soon  crossing  the  artery.  The  9th  nerve  is  just  below. 
For  lesion  of  this  vessel  in  the  face  it  can  be  readily  secured  as  it 
crosses  the  inferior  maxilla  in  the  depression  at  the  anterior  border 
of  the  masseter.  The  skin  should  be  well  pulled  up  from  the  neck 
before  making  the  incision,  so  that  after  healing  the  cicatrix  will 
fall  below  the  jaw. 


PHAEYNGEA   ASCENDENS. 

As  to  the  origin  of  this  branch  of  the  carotid,  the  anatomists  here- 
tofore quoted  give  the  ascending  pharyngeal  (Gray  and  Wilson), 
"  from  the  commencement  of  the  external  carotid.''^  Quain  and  Leidy, 
"about  on  a  level  with  the  linguaV^     Sappey,  as  "at  first  situated 


SURGICAL    ANATOMY    OF    CAROTID    AliTEKTKS.  19 

betwe'en  the  external  and  internal  carotids;"  and  IlyrtJ  "  from  the 
inner  aspect  of  the  exlernal  carotid.''''  In  their  diagrams  of  the  vessel 
both  Wilson  and  Gi'ay  give  the  origin  from  the  biCurcatioa  of  the 
common  carotid. 

I  found  it  derived  from  this  last  point  in  only  12  instances;  while 
in  111  cases  in  which  it  was  present,  and  from  the  external  carotid 
in  121  examinations,  its  average  distance  of  origin  from  the  bifur- 
cation was  .60  inch,  a  point  almost  opposite  the  lingiial^  as  given 
by  Leidy  and  Quain.  In  Fig.  2,  the  lines  radiating  from  P  give 
the  wide  range  of  this  vessel.  Between  the  centre  of  bifurcation 
and  one-half  inch  above,  26  per  cent,  were  foi;nd  ;  between  one-half 
and  one  inch  above,  69  percent.;  and  from  one  to  one-and-a-half 
inches  6  per  cent.  It  was  absent  from  the  external  carotid  in  ten  of 
121  examinations;  in  four  of  these  ten  it  was  from  the  internal 
carotid^  and  in  three  cases  hoth  of  the  terminal  divisions  of  the  cotn- 
mon  carotid  gave  off  an  ascending  pharyngeal.  Taking  the  12  cases 
derived  from  the  bifurcation,  and  82  from  one-half  inch  and  upwards 
from  this  point,  we  have  85  per  cent,  of  cases,  in  which  this  vessel 
is  removed  from  the  first  surgical  division  of  the  carotid.  Owing  to 
its  constant  small  size  (being  the  smallest  of  the  eight  regular 
branches),  its  presence  will  not  under  any  circumstances  contra- 
indicate  the  application  of  the  ligature,  because,  if  it  is  not  itself 
included  in  the  ligature,  the  inflammatory  process  following  the 
operation  would  occlude  so  small  a  vessel.  Extra  branches  in  con- 
nection with  its  origin  were  noticed  in  two  instances  of  111.  It  was 
from  a  common  origin  with  the  occipitalis  in  fifteen  instances. 

The  pliaryngea  ascendens  is  not  infrequently  wounded  in  operations 
about  the  tonsils  and  posterior  pharynx.  In  the  history  of  the 
carotids  there  is  one  death  from  hemorrhage  from  this  small  vessel. 

Operation  for  Ligature. — First  incision  same  as  for  lingucdis,  the 
transverse  being  parallel  with  and  one-eighth  of  an  inch  below  the 
lower  border  of  the  os  hyoides.  The  vessel  will,  in  the  majority  of 
cases,  be  found  between  the  two  carotids  and  about  one-eighth  of  an 
inch  below  the  hyoid  bone.  In  the  event  that  hemorrhage  was  not 
arrested  by  the  ligature  of  the  external  carotid  low  down,  ligature  of 
the  common  and  internal  carotids  would  be  justifiable,  since  in  twelve 
of  121  it  was  derived  from  the  septum  of  bifurcation  and  in  six  in- 
stances from  the  internal  carotid. 


20  PRIZE    ESSAY. 


OCCIPITALIS. 


"From  the  back  part  of  the  external  carotid  about  as  high  as  the 
faciaV  (Leidy.)  Hyrtl  nor  Wilson  gives  the  origin  of  this  vessel. 
While  Gray  says  "opposite  the/aaaZ."  Sappey  and  Quain  "oppo- 
site the  lingual  or  facial. "^^ 

The  occijntalis  was  present  in  120  of  121  cases,  and  the  average 
distance  of  its  origin  from  the  bifurcation  was  .96  inch  (see  Fig.  1), 
which  is  nearly  opposite  the  facial,  as  given  by  Gray  and  Leidy. 
In  Fig.  3  the  lines  radiating  from  0  indicate  the  wide  range  of 
origin  of  this  branch  of  the  carotid,  7  per  cent,  are  below  one-half 
inch ;  61  from  one-half  to  one  inch  ;  32  per  cent,  above  this  point, 
leaving  a  total  of  93  per  cent,  in  which  this  vessel  is  so  situated  as 
not  to  interfere  with  the  application  of  the  ligature  in  the  first  half 
inch  of  the  external  carotid. 

It  was  absent  in  one  of  121  cases,  a  branch  from  the  inferior 
thyroid  {not  the  cervicalis  ascendens)  taking  its  place  and  distribution. 

The  hypoglossal  nerve  wound  underneath  this  vessel  (at  or  very 
near  the  origin  of  the  sterno -mastoid  branch  of  the  occipital)  and  turned 
forward  to  its  distribution  in  the  tongue  invariably.  No  feature  of 
the  anatomy  is  so  constant  as  the  relation  between  this  nerve  and 
artery. 

I  would  offer  this  explanation  ;  the  nerve  is  distributed  well  for- 
ward in  the  tongue,  which  (as  is  well  known)  is  the  most  movable 
organ  in  the  economy.  If  the  nerve,  coming  out  of  the  condyloid 
foramen,  went  directly  to  its  distribution,  the  sudden  and  forcible 
protrusion  of  the  tongue  would  rupture  or  interfere  with  the  func- 
tion of  the  nerve.  To  avoid  this  accident  it  at  first  descends,  and  is 
looped  underneath  an  elastic,  yielding  artery,  which  prevents  its 
being  violently  stretched  and  serves  to  pull  it  back  after  the  organ 
is  drawn  within  the  mouth. 

In  15  of  120  cases,  this  vessel  was  common  in  its  origin  with  the 
ascending  pharyngeal ;  in  eleven  other  instances  with  the  auricularis 
posterior,  being  abnormally  associated  in  26  of  120  cases.  The  mastoid 
branch  of  the  occijntalis,  which  is  given  by  Wilson,  Hyrtl,  and 
Richardson  as  one  of  the  branches  of  the  external  carotid,  was  only 
derived  from  the  carotid  in  15  of  120  dissections. 

The  common  carotid  was  tied  in  several  instances  (see  History)  for 
injury  to  this  branch. 

Of  its  branches  the  arteria  princeps  cervicis  may  be  considered  the 


SURGICAL    ANATOMY    OF    CAROTID    ARTERIES.  21 

most  important  in  a  surgical  sense,  though  not  so  important  a  factor 
in  carrying  on  the  collateral  circulation  as  is  usually  thought.  It 
and  the  prof  imda  cervicis  from  the  superior  intercostal  (or  subclavian) 
are  both  quite  small,  and  the  anastomosis  in  many  instances  cannot 
be  demonstrated. 

The  occipital  artery  is  sixth  in  size  of  the  branches  of  the  carotid. 

Operation  for  ligature, — !N'ear  its  origin  same  as  for  ligature  of 
facial^  only  the  transverse  incision  should  extend  posteriorly.  Should 
the  emergency  demand  it  may  also  be  secured  just  underneath  the 
origin  of  the  digastricus^  though  quite  deeply  situated  here.  After 
it  reaches  the  scalp  it  is  more  accessible,  and  does  not  demand  de- 
scription. 

AUEICULARIS   POSTERIOR. 

In  117  cases  in  which  it  was  present  in  121  the  average  origin 
was  1.89  inches  above  the  centre  of  bifurcation  (see  Fig.  1).  Its 
variations  are  shown  in  Fig.  4.  2  per  cent,  between  three-eighths 
and  one  inch;  67  per  cent,  between  one  and  two  inches;  30  per 
cent,  above  this.  As  far  as  ligature  of  the  external  carotid  is  con- 
cerned, this  branch  does  not  demand  consideration.  It  is  noticeable 
that  the  posterior  branches  of  the  externcd  carotid  (the  pharyngeal^ 
occipita\  and  auricular')  are  much  more  uncertain  and  irregular  in 
their  origins  than  the  anterior;  the  thyroid  being  of  all  most  constant. 
The  auricularis  was  absent  in  4  of  121  cases,  the  occipital  taking  its 
distribution.  In  11  of  the  117  instances  in  which  it  was  present  it 
was  in  common  with  the  occipitalis.  It  has  been  ligatured  in 
several  instances,  once  by  the  elder  Pancoast,  of  Philadelphia. 

On  account  of  its  intimate  relations  with  the  facial  nerve  in  front 
of  and  the  spinal  accessory  underneath  it,  as  it  winds  below  the  car- 
tilage of  the  ear,  I  do  not  deem  it  advisable  to  attempt  to  tie  it  in 
this  position. 

It  will  usually  be  found  on  a  line  with  the  upper  margin  of  the 
posterior  belly  of  the  digastric. 

It  is  seventh  in  size  of  the  eight  branches  of  the  carotid. 

RAMI  PAROTIDEI. 

Above  the  origin  of  the  auricularis  posterior^  and  within  the  sub- 
stance of  the  parotid  gland,  a  number  of  small  branches  are  dis- 
tributed to  the  structure  of  the  parotid. 


22  PEIZE    ESSAY. 

The  external  carotid  a  little  beyond  these  branches,  and  when 
opposite  the  neck  of  the  condyle  of  the  inferior  maxilla  terminates 
by  dividing  into  the  maxillaris  interna  and  temporalis. 


MAXILLAEIS    INTEENA  AND  TEMPOEALIS. 

This  division  of  the  carotid  averaged  a  distance  of  2.93  inches 
from  the  centre  of  bifurcation  (see  Fig.  1).  The  variation  in  the 
length  of  the  external  carotid  will  be  seen  in  Fig.  4.  In  rare  in- 
stances (2)  it  was  only  two-and-a  quarter  inches  long,  and  in  one 
case  it  reached  the  length  of  four  inches.  Jn  95  per  cent,  it  was 
found  to  be  from  two-and-a-half  to  three-and-a-half  inches  long. 
The  maxillaris  interna  was  largest  in  24  of  77  cases,  being  second  in 
size  of  the  eight  branches. 

The  temporalis  was  fifth  in  size. 

In  lesions  of  the  temporal  on  the  scalp  this  vessel  may  be  readily 
secured  in  front  of  the  ear  when  it  passes  over  the  zygoma.  If 
wounded  near  its  origin  the  external  carotid  may  require  the  ligature 
above  or  at  the  digastric.  The  transverse  facial  branch  runs  parallel 
with  and  is  in  relation  to  the  zygoma  above  and  the  parotid 
(Steno's)  duct  below. 

Lesions  of  the  maxillaris  interna  require  ligature  of  the  external 
carotid  below  the  maxillaris  externa^  with  which  it  anastomoses 
freely  on  and  in  the  face.  A  not  infrequent  cause  of  this  operation 
is  hemorrhage  or  lesion  of  the  meningeal  arteries.  It  will  be  seen 
that  this  vessel  (like  the  facial)  is  widely  distributed. 


SOME  POINTS  EELATING  TO  THE  EXTEENAL  CAEOTID  IN  GENEEAL. 

It  is  not  safe  to  rely  upon  a  symmetrical  arrangement  of  the 
external  carotids  and  their  branches  upon  the  two  sides.  In  15  cases 
examined  upon  both  sides  of  the  same  cadaver,  in  7  there  was  some- 
thing of  symmetry  (thougb  not  very  marked).  In  8  there  was  no 
attempt  at  a  symmetrical  arrangement. 

lu  121  dissections  there  were  found  of  the  eight  regular  branches 
of  the  carotid^  coming  directly  from  the  main  trunk,  888  out  of  a 
possible  sum  of  968.  This  deficit  is  explained  thus:  in  16  cases  a 
single  branch  was  wanting;  in  60  instances  two  had  a  common 
origin ;  and  in  tioo  other  instances  three  branches  came  off  from  a 
single  trunk. 


SURGICAL    ANATOMY    OP    OAUOTID    AR'l'EIUKS.  23 

Excluding  tlie  brandies  above  the  j)OHl,itr!.()r  a'ihrwilfir.\i^o\u<^  to  the 
parotid  gland,  there  were  48  eases  in  wliieli  extra  or  abnormal 
branches  came  from  the  external  carotid^  the  number  of  these  being 
62,  distributed  to  the  hyoid  region,  tonsils,  constrictor,  and  mastoid 
muscles.  They  were  all  too  small  to  contra-indicate  the  application 
of  tlie  ligature  to  the  parent  trunk. 

THE  OPERATIVE  SURGERY  OF  THE  TRIGONUM  COLLI  SUFERIUS  AND 
TRIGONUM  SUBMAXILLARE. 

Ligature  of  the  Common  Carotid  Artery  and  Internal  Jugular 
Vein. — A  line  extending  from  the  tragus  of  the  ear  to  the  sterno- 
clavicular articulation  will  cover,  and  be  parallel  with,  the  internal 
and  common  coroileV/ arteries  in  their  surgical  length.  This  line  will 
strike  the  centre  of  bifurcation  of  the  primitive  carotid  almost  in- 
variably on  a  level  with  the  upper  border  of  the  thyroid  cartilage, 
and  will  strike  the  anterior  edge  of  the  sterno-mastoideus  from  one 
inch  and  a  quarter  to  one-and-a-half  below  this  level. 

The  incision,  being  made  with   its  direction,  as  above  given,  its 
centre,  about  one  inch  below  the  bifurcation,  extending  from  one- 
and-a-half  to  two  inches  above  and  below  this  point,  will  divide  first 
the  integument,  and  with  this  the  thin  platysma  mTjoides^  some  fila- 
ments of  the  superficialis  colli  nerve,  of  no  importance,  and  some 
small  veins  passing  from  the  anterior^  either  to  the  internal  or  ex- 
ternal jugular  veins.     About  the  centre  of  the  wound  the  edge  of  the 
7nastoideus  will  be  seen,  and  below  this  (usually)  the  anterior  belly 
of  the  omo-hyoideus.     The  sheath  of  the  carotid  and  jugular  vein  is 
now  exposed,  often  crossed  by  the  thyroid  veins,  and  the  cervicalis 
descendens   artery;    the    descendens   noni   nerve   almost    invariably 
lying  upon  the  centre  of  the  sheath,  it  being  parallel  with  the  axis 
of  l\xQ  common  i\.x\di  internal  carotids.     In  two  instances  I  have  seen 
the  superior  thyroid  artery  turn  directly  down,  in  front  of  the  com- 
mon trunk,  for  ah  inch  or  more,  and  then  turn  abruptly  inwards  to 
be  distributed  to  the  thyroid  body.     Under  such  abnormal  condi- 
tions this  vessel  would  probably  be  divided.      The  communicans 
noni  is  occasionally  found  crossing  the  sheath  from  without,  inwards, 
to  anastomose  with  the  descendens.     These  nerves  will  be  drawn  to 
the  outer  or  inner  side  of  the  wound,  as  is  most  convenient.     The 
sheath  should  be  opened  on  its  tracheal  side  as  far  as  possible  from 
the  jugular  vein,  and  the  needle  passed  from  without,  inwards,  being 
kept  close  to  the  artery  in  order  to  avoid  wounding  the  vein  or  in- 


;24  PRIZE    ESSAY. 

eluding  the  pneumo gastric  or  symjjaihetic  nerves.  I  am  of  the  opinion 
that  the  sheath  should  be  well  opened,  and  the  artery  clearly  ex- 
posed, so  that  the  needle  may  be  manipulated  with  more  of  certainty 
and  less  danger  from  these  too  common  and  unfortunate  accidents. 
In  several  instances  the  artery  has  been  transfixed;  the  jugular  has 
been  wounded ;  the  pneumogast7'ic  or  sytnpathetic  nerves  included 
in  the  ligature,  for  want  of  precision  in  separating  the  artery  from 
the  vein.  Certainly  the  danger  of  slough  in  the -artery  is  not  so 
great  as  the  dangers  above  enumerated.  Just  as  the  needle  is  being 
introduced,  pressure  above  upon  the  vein  would  empty  it  of  blood, 
and  of  course  diminish  the  danger  of  wounding  it.  This  pressure 
should  not  be  long  continued,  since  interference  with  the  return  of 
blood  from  the  brain  is  never  without  danger  during  the  adminis- 
tration of  an  ansesthetic. 

The  internal  jugular  vein  can  be  secured  by  this  same  operation, 
it  being  on  the  outer  side  of  the  artery,  and  concealed  by  the  sterno- 
mastoid  muscle.  The  needle  should  be  passed  from  within  out- 
wards, to  avoid  the  nerves. 

Ligature  of  the  Internal  Carotid. — The  incision  should  be  made  in 
the  same  direction  as  given  for  the  common  trunk,  with  its  centre 
from  one-half  to  three-quarters  of  an  inch  above  the  upper  border  of 
the  thyroid  cartilage.  The  same  structures  will  be  divided  super- 
ficially, and  the  veins  will  be  seen  superficial  to  the  artery.  As 
shown  in  (7,  Fig.  9,  they  may  cross  the  internal  carotid  almost  at 
right  angles,  or  (as  in  A  or  B)  they  may  empty  into  a  single  trunk, 
and  run  parallel  with  the  external  carotid.  This  last  is  the  most 
usual  way,  but  it  will  be  scarcely  possible  to  ligate  the  internal 
carotid  without  division  and  ligature  of  these  veins.  The  descendens 
noni  nerve  will  be  seen  running  along  the  artery,  the  hypoglossal 
crossing  it  about  one  inch  from  the  bifurcation.  The  vessel  being 
exposed  the  needle  is  introduced  on  the  outer  side,  avoiding  the 
jugular  vein  and  prieumogasti^ic  nerve  externally,  the  external  carotid 
internally,  and  the  hypoglossal  nerve  superficially.  The  pharyngea 
ascendens  is  in  intimate  relation  to  the  internal  carotid  running  par- 
allel with  it  on  its  inner  aspect.  Occasionally  the  first  cervical 
ganglion  of  the  sympathetic  extends  as  low  as  this  point.  It  will 
be  avoided  by  keeping  the  needle  close  to  the  artery. 

The  complicated  and  deep  relations  of  this  vessel  above  the  angle 
of  the  jaw  render  it  difficult  to  be  reached,  yet  in  hemorrhage  from 
lesion  of  the  artery  here  the  vessel  should  he  exposed  and  secured 
above  and  below  the  lesion. 


SURGICAL    ANATOMY    OP    CAROTID    ARTERIES.  25 

Ligature  of  the  External  Carotid. — This  vessel,  heretofore  so  rarely 
ligatured,  may  be  tied  in  the  majority  of  cases  at  two  points,  viz., 
between  the  origins  of  the  thyroidea  superior  and  linrjualis,  about  one- 
quarter  of  an  inch  above  the  septum  of  bifurcation  (see  Fig  I),  or 
between  the  origins  of  the  maxillaris  externa  and  auricularis^  about 
one  and  one-half  inches  above  the  tJiyrnid  cartilaf/e.  At  the  lower 
point  of  election  the  operation  is  the  same  as  for  ligature  of  the  inter- 
nal carotid  on  the  same  plane,  except  that  the  external  carotid  is  usually 
from  one-quarter  to  one-half  inch  nearer  the  median  line  than  the 
internal. 

Notwithstanding  that  the  analysis  of  these  121  consecutive  dis- 
sections has  convinced  me  of  the  propriety  of  ligaturing  this  vessel, 
and  that  the  history  of  the  cases  in  which  it  has  been  tied  shows  a 
rate  of  mortality  far  below  that  of  ligature  of  the  common  carotid, 
yet  the  proximity  of  large  and  important  branches  to  each  other,  or 
to  the  bifurcation  of  the  common  carotid  in  many  instances,  as  shown 
in  the  following  table  of  measurements,  makes  it  of  the  utmost  im- 
portance that  the  surgeon  should  proceed  with  great  care  and  dis- 
cretion. The  wound  should  be  thoroughly  cleaned,  and  the  vessel 
examined  with  scrupulous  care  above  and  below  the  ligature,  and 
any  collateral  branch  or  branches  within  less  than  one-quarter  of  an 
inch  should  be  also  secured. 

In  many  of  the  cases  given  in  the  history  of  the  external  carotid 
this  precaution  was  not  taken.  If  the  result  heretofore  has  only 
been  a  mortality  of  6|  per  cent.,  with  a  closer  study  of  this  important 
vessel,  and  the  adoption  of  conservative  measures  which  comes  of  a 
thorough  understanding  of  the  surgical  anatomy,  can  we  not  hope 
that  even  this  death-rate  may  in  future  be  decreased? 

Should  the  artery  be  found  to  be  normal  (as  in  Fig.  1),  I  would 
place  the  ligature  nearer  the  lingualis  than  the  bifurcation,  and  tie 
the  lingua.1  separately.  If  (as  in  Fig.  7)  a  rare  form  should  exist,  I 
would  ligature  close  to  these  branches,  and  tie  each  of  them  in  rts 
turn.     This  same  conservative  rule  must  apply  to  every  case. 

The  operation  at  or  above  the  posterior  belly  of  the  digastric  is 
comparativelj'-  safer,  and  is  applicable  to  all  lesions  above  this  point. 
The  incision  is  the  same  as  the  preceding,  except  that  its  centre  must 
be  about  one-and-one-half  inches  above  the  thyroid  cartilage. 

Above  this  level,  that  is,  after  the  artery  enters  the  parotid  gland, 
it  is  so  situated  that  it  should  not  be  cut  down  upon.  The  incision 
would  involve  the  facial  nerve,  causing  paralysis  of  the  muscles  of 
expression.     In  malignant  disease  of  the  parotid,  where  this  gland 


26  PRIZE    ESSAY. 

is  removed  the  vessel  may  as  well  be  secured  here  as  not,  since  the 
operation  itself  usually  destroys  the  facial  nerve. 

It  is  a  remarkable  fact,  that  notwithstanding  the  close  proximity 
of  the  branches  of  the  carotid,  in  a  number  of  instances  in  which  it 
has  been  ligatured  without  the  precaution  of  securing  immediate 
collateral  branches,  there  has  not  followed  secondary  hemorrhage. 
No  explanation  of  this  fact  has  appeared  so  definite  as  the  one  given 
by  Prof.  H.  B.  Sands, "^  "  which  takes  into  account  the  remarkable 
reparative  power  of  the  tissues  surrounding  this  vessel.  Suppura- 
tion is  extremely  rare;  and  the  wounded  tissues  soon  become  con- 
solidated by  plastic  material,  and  secondary  hemorrhage  is  prevented 
by  changes  occurring  outside  of,  as  much  as  by  changes  taking  place 
ivitJmi  the  vessel  ligatured." 


CONCLUSION. 

I  cannot  conclude  the  surgical  anatomy  of  these  arteries  without 
protesting,  with  all  the  earnestness  I  may  possess,  against  the  ope- 
ration of  tying  the  common  carotid  for  lesions  of  the  external  carotid 
or  its  tranches  when  this  last  vessel  may  be  ligatured.  The  death- 
rate  after  the  ligature  of  the  common  carotid,  as  seen  in  the  conclu- 
sions to  the  history  of  this  vessel,  is  (forty-one)  41  per  cent.  That 
of  the  external  carotid  is  (four  and  one-half)  4|-  per  cent. 

Before  such  startling  facts,  the  theories  of  eminent  men,  and  the 
teachings  of  surgery  to  within  the  present  generation,  cannot  endure. 

'  Prof,  of  Surgical  Anatomy  in  the  College  of  Physicians  and  Surgeons,  New  York. 


SURGICAL    ANATOMY    OF    CAROTID    ARTERIES. 


27 


TABLE 


SHOWING  THE   DISTANCE   OP   ORIGIN   OF  THE   EIGHT  KEGULAR  BHANCHES   OF 
THE  EXTEUNAIi   CAROTID   ARTERY   FROM    TIfE   CENTRE   OF  BIFUR- 
CATION OF  THE  COMMON  CAROTID  AND  FROM  EACH  OTHER. 


Explanations. — The  letters  R.  and  L.  in  the  first  column  indicate  that  the  ar- 
tery was  from  the  Eight  or  Left  side,  and  when  connected  by  the  brace  , \ 

they  were  from  the  same  subject.     The  , ^  extending  from  one  column  to 

another  indicates  that  the  two  arteries  it  connects  were  from  a  common  trunk. 
The  measurements  were  made  from  the  centre  of  the  Bifurcation  of  the  Common 
Carotid  Artery,  as  shown  in  the  diagram.  The  origin  of  the  Superior  Thyroid, 
when  not  otherwise  noted,  is  above  the  centre  of  bifurcation,  that  part  of  an  inch 
represented  by  the  figures  in  its  columns. 


-a 

-o 

"^ 

S 

?7 

o 

to  bo 

3 

'c3 

^ 

.2  'S 

s 

-Pi 

<u 

SO 

c3 

^■s. 

■f-i^ 

-5  •< 

p< 

a 

SS 

X 

Hi 

C3 

o 

w 

cc 

Hi 

^ 

< 

O 

PL, 

H 

No. 

5 

8 

1 

5 

8 

i 

1 
2 

Z. 

8 

1^ 
^4 

2 

8 

2i 
2i 
If 
If 

3i 
3i 

2| 
2| 

2f 

2f 

H 

1.  R. 

2 
Opposite  Bifurcation. 

1 

■    2 

L 

2 

31 

2.  L. 

8 

1 
8 

1 

H 

3.  R. 

Opposite. 
Opposite. 

f 

2| 

4.  L. 

1 

1* 

2^ 

5.  L. 

^8 

i 
2 

If 

3i 

6.  R. 

J. 
2 

1 
2 

1 

1. 
2 

2f 

7.  L. 

f 

f 

2f 

8.  L. 

2i 

2^ 

^8 

9.  R. 

Opposite. 

5 

8 

1 

From 
Bifurcation. 

3 

4 

If 

2f 

93 

-"4 

10.  L. 

8 

n 

3 

4 

8 

5 

8 

1 
4 

2 
2i 

3 

21. 

3 

3 

11.  R. 

JL 

1 

2 

2i 

12.  L. 

3 
4 

3 

4 

3 

13.  R. 

a 

i 
2 

1 

1 
2 

1 
2 

If 

3 

3 

14.  L. 

u 

1 
2 

1 

0 

3 
4 

2 

3 

3 

15.  L. 

1 

T6 

f 

,5 

8 

0 

1 

If 

2f 

2^ 

16.  R. 

1 

2 

7 
8 

1 
8 

5 
8 

2 

2| 

n 

17.  L. 

Opposite. 

f 

1 

3 
4 

-^8 

If 

03 
-4 

0-3 
-4 

28 


PRIZE    ESSAY. 


'3 

■3 
bo 

g 
3 

"3 
•s 

"3 

a  t^ 

3 
0 

0 

Ph 

1 
0 

a 

1— ( 

No. 

18.  R. 

2. 

8 

i 

1 

5 

8 

1 
8 

If 

2| 

2f 

19.  R. 

Opposite. 

8 

1 

8 

1 
4 

1 
4 

2 

H 

n 

20.  L. 

a 

f 

5 

8 

f 

f 

li 

H 

2i 

21.  L. 

a 

f 

1 

3 

4 

^ 

1| 

H 

3i 

22.  L. 

a 

3. 

8 

1 

2 

0 

1 

If 

2^ 

■^4 

2| 

23.  L. 

u 

3 

4 

1 
8 

1 

2 

3 

4 

0 

^8 

2f 

2f 

24.  L. 

1 

2 

1. 

2 

5 

8 

5 

8 

n 

25.  L. 

8 

li 

If 

li 

2i 

2f 

4 

4 

26.  L. 

Opposite. 

u 

Opposite. 

4 

Opposite. 

5 

8 

8 

3 

4 

3 

4 

1 
2 

1 
2 

If 

2i 
2i 

2 
2 

3 

H 
H 
H 

n 

2| 

3 

2t.  L.  ■ 

1. 

2 

2 

3i 

28.  R. 

1 

5 

8 

5 

8 

H 

29.  L. 

5 

8 

5 
8 

H 

30.  R. 

i 

1 

r" 

1 

2 

From 
Bifurcation. 

1 

H 

31.  L. 

i 

1 
2 

2| 

32.  R. 

1 
4 

1 
4 

2| 

33.  L. 

u 

1 

8 

J 

3 

4 

1 

5 

8 

5 

8 

^4 
If 

2f 
3 

2f 

34.  R. 

3 

4 

3 

4 

3 

35.  L. 

Opposite. 

u 

.5 

8 

1* 

3 

4 

7 
8 

1 
8 

2i 

8 

2| 

3 

36.  R. 

2. 

4 

3 

4 

21 

37.  R. 

1 

4 

1 

7 
8 

3 

4 

7 
8 

2 

3 

3 

38.  L. 

Opposite. 

1 

1 

1 

f 

2i 

2| 

2| 

39.  R. 

4( 

1 

n 

0 

2 

2| 

3i 

H 

40.  R. 

1 

2 

1 

4 

i 

5 

8 

li 

2| 
2i 

2| 

41.  L. 

1^ 

If 

2i 

42.  R. 

(( 
(( 

1 
2 

1 

8 

i 

i 
8 

4 

1 

If 

2 

2i 

2| 

3 

3 

2| 

43.  L. 

3 

8 

f 

3 

44.  R. 

f 

f 

i. 
4 

4 

3 

45.  R. 

Opposite. 

I 
2 

1 

f 

5 

8 

If 

2| 

2| 

46.  L. 

u 

3 

4 

li 

3 

4 

1 

2| 

3i 

3i 

47.  R. 

(C 

5 
8 

7 
8 

0 

1 

0 

2| 

2| 

48.  L. 

(( 

1 
8 

1 

1 

1* 

2 

3 

3 

49.  R. 

(( 

1 

H 

5. 
8 

15 

2i 

3 

3 

SURGICAL    ANATOMY    OF    CAliOTIJJ    AltTEHlES. 


29 


i2 


50.  L. 

Opposite. 

51.  R. 

u 

52.  L. 

u 

53.  L. 

u 

54.  L. 

yL  below 

55.  R. 

Opposite. 

56.  L. 

u 

51.  R. 

u 

58.  R. 

i 

59.  L. 

Opposite. 

60.  L. 

i 

61.  R. 

i 

62.  L. 

Opposite. 

63.  R. 

i 

64.  R. 

i 

65.  L. 

Opposite. 

66.  R. 

f 

67.  R. 

4 

68.  L. 

Opposite. 

69.  L. 

u 

70.  L. 

i . 

71.  R. 

1 

2 

72.  L. 

Opposite. 

73.  L. 

a 

74.  R. 

i 

75.  L. 

Opposite. 

76.  R. 

u 

77.  L. 

a 

78.  L. 

a 

79.  R. 

i 

80.  R. 

f 

81.  L. 

i 

1 

2 

1 
8 

t 

5 

'8 

1 
2 

JL 

2 

1 

2 
5 


2 


5. 

8 

^8 


s 

1 

s 


1^ 


^4 

8 


op. 

i. 

2 


op^ 

n 

op. 

5. 

8 


5 

4 

5 

8 


5 

8 

5. 

8 


If 
1 

2 
15 


i 

1 

If 

8 

1 

1| 

.5 

8 

3 

4 

2 

op. 

1 

2 

If 

1 

1 

2 

i 

2 

li 

2 

2 

1 

1 

5 

8 

H 

2 

i 

i 

2i 

>P. 

If 

2i 

H 

^8 

2 

If 

21 

2 

1^ 

•■■8 

2 

93 

-8 

2i 
2i 
11 
If 


22- 

H 
H 

2i 

2i 


2t 
2i 
3 

2| 


2i 

2| 
93 

^^4 

^8 

H 

2| 
31 


2i 

3i 

3 

2| 

2^ 

-^4 

2i 

H 
H 


95 


2J 

H 
H 

^2 

2i 

2f 
2^ 


93 

^4 

3 

2i 
2| 
2| 
H 

H 

2| 

^4 

3 

3 

2i 

3i 


2| 

2| 
9i 


2* 
^4 
^4 


30 


PRIZE    ESSAY, 


t3 
O 

2 

CO 

bo 

a 

"3 

1« 
be  bo 

a  a 

[p. 
O 

O.rH 

'3 

"3 

No. 

i 

1 

1 

2 

3i 

82.  L. 

1 

7 
8 

H 

83.  R. 

1. 

8 

1 

H 

li 

n 

2 

21 

n 

84.  L. 

1 

If 

If 

li 

H 

2i 

3i 

3i 

85.  L. 

1 
4 

li 

li 

1 

1 

0 

3i 

3i 

86.  L. 

1 
4 

i 

If 

1 
4 

H 

n 

3i 

H 

81.  R. 

3. 

8 

1 

If 

0 

H 

2 

3i 

H 

88.  R. 

4 

i 

H 

0 

1 

2 

3 

4 

7 
8 

2i 
2^ 

3 

H 

.3 

89.  L. 

i 

i 

3i 

90.  L. 

1 

4 

1 

2 

1 

JL 

2 

li 

If 

2| 

2| 

91.  L. 

Opposite. 

1 

li 

3 

4 

1 

2 

3 

3 

92.  L. 

u 

1 

n 

f 

If 

2i 

3i 

H 

93.  L. 

1 

1 

8 

1 

8 

JL 

4 

1 

4 

1 
2 

2 

2i 
3 

H 

94.  R. 

3 

4 

3 

4 

3 

95.  L. 

Opposite. 

u 

1 

7 
8 

op. 

1 

8 

5 
8 

15 
0 

2f 
2i 

2f 

96.  R.* 

J. 

8 

1 

8 

n 

Q1.  R. 

1 

4 

1^ 

-■-8 

-^8 

0 

1| 

2| 

3i 

H 

98.  R. 

1 
8 

1 

4 

3 

4 

1 

JL 

2 
4 

n 

2i 

2i 
3i 

H 

99.  R.f 

1 

1 
2 

5 

8 

If 

5 

8 

If 

H 

100.  L.J 

1 

4 

4 

4 

3i 

101.  R. 

Opposite. 

a 

1 

2 

3 

4 

5 

8 

I 

i 

1 
2 

3 

4 

If 

2| 
3 

3 

21 

2| 

102.  L. 

4 

3 

4 

1 

3 

4 

3 

103.  L. 

If 

If 

2 

3 

104.  L. 

1 

1 

2| 

105.  R. 

1 

2 

3 

4 

3 

4 

1 

JL 

2 

If 

3 
3 

3 

106.  L. 

1 
8 

7 
8 

3 

101.  L. 

a 

1 

2 

H 

op. 

H 

H 

2| 

2| 

108.  L. 

u 

1 
2 

■  1 

i. 
2 

1 

2 

2 

2| 

2| 

109.  L. 

^  above. 

4 

1 

1| 

1 
1 

H 

1| 

3 

31 

3 

110.  L. 

5 

8 

5 

8 

H 

li 

3i 

111.  R. 

Opposite. 

1 

1 

3 

4 

1 

If 

2| 

n 

112.  L. 

§            I"  below. 

1 
2 

3 

4 

op. 

op. 

li 

2i 

2i 

113.  L. 

Opposite. 

3 

4 

1 

3 

4 

7 
8 

2 

3 

3 

SURGICAL    ANA.TOMY    OF    CAROTID    ARTERIES. 


31 


■a 
'S 

"^ 

bo 

3 

OS 

'3 

fcoio 

a  =) 

*t5 

o 

No. 

114.  L. 

Opposite. 

f 

1 

op. 

1 

2i 

3 

3 

115.  R. 

^  above. 

i       " 
Opposite. 

1 

n 

1 

op. 

3 
4 

1 

2 

H 
3 

3-'- 

•-*8 

3i 

116.  L. 

1 

1 

3 

111.  L. 

2i 

2i 

3^- 

118.  R. 

I  above. 

3 
4 

3 
4 

0 

1 

li 

3 

3 

119.  L. 

Opposite. 

1 

li 

1 

H 

2i 

n 

2| 

120.  R. 

-^  above. 

7 
•       8 

H 

7 
8 

i| 

2^ 

H 

3^ 

121.  L. 

i       " 

1 

li 

li 

li 

2i 

H 

3i 

Total  distance 
above  bifur- 
cation      12.81 

Average  dis- 
tance  11- 


82.56  110.99    67.31  115.80  221.8t  355.12  inches 
.68+     .92+      .60+    .96+     1.89+    2.93+      " 


*  This  case  bifurcated  ^  inch  above  the  upper  border  of  the  thyroid  cartilage. 


All  the  remaining  cases  were  opposite  this  point. 

Total  121.     On  right  side,  50  dissections ;  on  the  left,  71. 

[Note. — Each  measurement  in  these  tables  was  made  with  compass  and  rule,  and 
noted  at  the  time  the  dissection  was  being  made.  It  was  thought  unnecessary  to 
measure  below  the  ^  of  an  inch  in  general.  ] 


SURGICAL  HISTORY 


COMMON  CAROTID  AETERY, 


34 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


o 

■w  a 

s  »■ 

o  o 

o  X 

^  f3 

OS 

-2  ci 

re   tS 

p. 2 

P 

■n 

pa 


Abernethy, 
1803. 


Adelmann, 

1841. 
Adelmann, 

lSr>3. 

Adelmann, 

1 

Adolphus,  P. 

1862. 
Alexander, 
C.  T.,  1862. 

Andrews,  E., 
Chicago. 

Anandale,  T.. 
1875. 


Angell. 

do. 
Ansiaux. 

Ai'sndt, 
1821. 


Arnold,  G.  C, 
New  York,  1874. 


Arnott. 

Auchincloss, 

1S39. 

Aubert, 

Moscow. 

Awl,  Wm.L. 

1827. 


Baizeau,  1817. 


Baker,  J.  W., 

1870. 

Baker,  W.  M. 

1S7.7. 


Von  Balass 
1854. 


Von  Balassa, 
1844. 


Ballingal,1854, 
East  India. 


Norris  Contributions, 

Pbila.,  1873;  Dr.  C. 

Pilz,  in  Langenbeck's 

Archiv  fiir  Klinisclie 

Chirurg.,  1868. 

Arch.  Klin.  Chir. 

(cit.) 

do. 

do. 

Med.  Surg.  Hist.  Re- 
bellion— Dr.  Otis, 
do. 


Letter  to  author. 


Brit.  Med.  Jr.,  Oct. 
1875. 


Arch.  Klin.  Chir. 


do. 
do. 


Letter  to  author. 


Lancet,  1846,  p.  135. 

Norris  Contrib.  Arch. 

KliD.  Chir. 

Arch.  Klin.  Chir. 

Ext.  Lancaster,  Ohio, 

Gazette,  March  20, 

1827,  kindness  Prof. 

J.  H.  Pooley. 

Arch.  Klin.  Chir.  1868. 


Lancet,  June,  1870. 

Am.  Jr.  Med.  Sci., 
July,  1877,  p.  176. 


Arch.  Klin.  Chir. 
do. 

do. 


Mid 

age. 

19 


Hemor'ge;  wound 
throat ;  gored  by 
cow. 


Hem.  of  tongue. 

Removed  cancer; 

tongue. 
Removed  superior 

maxilla. 
Shot  wound  inf. 

maxilla. 
Fragment  of  shell, 

temporal  region. 

Stab  wound  inter- 
nal carotid,  high 
up. 

Aneurism  ;  arch  of 
aorta. 


Epilepsy. 


do. 
Removed  parotid. 


Aneurism  anast. 
of  face. 


Hemorrhage  after 
removal,  recur- 
rent tumor,  an. 
gle  of  right  inf 
maxilla. 


Hemor'ge,  mouth; 

fall  on  pipe-stem. 
Aneurism  anast. 

of  head. 
Aneurism  anast. 

of  ear. 
Removed  immense 

tumor    of     right 

cheek. 


Hemorrliage  ;  fis- 
tulous opening 
near  ear. 


Hem.  ;  removed 
parotid  gland. 

Hemorrhage;  as- 
cend, pharynge- 
al ;  fall  on  pipe- 
stem. 

Prep,  resection  of 
inf.  maxilla. 

Aneurism  of  com- 
mon carotid. 


Pew 
hours. 


5  days. 


12  days 


23 
years. 


Some 
time. 


17  days- 


15 

years. 

3  years. 


18 
months. 


Below 
omo- 
hyoid. 


At  omo- 
hyoid. 


Above 
omo- 
hyoid. 


Dec.  28, 
1861. 


Sept.  6. 

Jan.  18, 

1862. 


1,2,3 
da.ys. 


THE    COMMON    CAKOTID    AKTBRY. 


85 


Common  Carotid  Artery. 


Date  of 
opei'iitiou. 


%-.  ^  Cm 

t.    !-(  ° 

O    0  <B 

ffi   o  c« 


0    .  p. 

q  O   O 


Recovery. 


Condition. 


CiiiiHo  of  (loath, 
(Into  after  op. 


KEMAUKS. 


Nov.  10, 

18-11. 
Oct.  14, 

18.j:j. 


Sept.  G, 
1SI12. 

Jan.  18, 
1862. 


March  2, 
lS7u. 


Nov.  IS, 
1821. 


Feb.  19, 
1874. 


May  27, 
1847. 


Sep.  23, 
1875. 


Jan.  18, 
1804. 


Feb.  22, 
1814. 


Aug.  17, 
1834. 


11  and 
17  day.s. 


Onco, 
middle 
meniug. 


6  w'ks. 


Imme- 
diately. 


Some 
dayss. 


1,  2,  3 
days. 


2a 
days. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 

Recovered. 

Recovered. 

Recovered. 


Recovered. 
Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


"Total  and 

temporarily 

disabled." 

Cured. 


Improved. 


Cured. 


Partial  and 
permanent 
paralysis. 


Cured. 


Cured. 


Cured. 


Cured. 


30  1iours.    ? 


3d  day.    7 


Died. 


Cerebral  anaamia? 


Inflammation  brain. 


3d  day  ;  exhaustion 
and  cerebral  anae- 
mia. 


Few  hours  after  op- 
eration. 


62d   day.     Cerebral 
softeninsr. 


I'ara'yfiH  of  rljzht  Bid'-  after  ope- 
ration ;  lingual,  facial,  niiperlor 
tliyroid,  and  iuti^rual  carotid  ar- 
teries were  wounded. 


Died  3  months  later  from  cancer. 

Two  ligatures  applied  a   short 
diotance  apart. 


"Seven  months  after  operation 
tumor  very  much  reduced  in 
pize  ;  bruit  not  po  loud  ;  carbol- 
ized  catgut."     Wardrop. 


Ligature  several  days  before  op- 
eration for  removal. 

The  secondary  hemorrhage  last- 
ed for  several  day.-',  but  was 
slight;  12  ligatures  were  ap- 
plied du.ring  the  operation. 

No  anajsthetic  :  tumor  removed 
on  7th  ;  hemorrhage 9th,  and  at 
intervals  to  19th  ;  after  opera- 
tion of  ligature  hemorrhage 
controlled  by  compress  ;  stu- 
por ;  5  days  after  operation  par- 
tial paralj'sis  right  face,  com- 
plete of  Ifft  arm  and  leg ;  27 
mouths  after  operation  partial 
paralysis  of  leg,  complete  of 
arm. 

It  is  stated  that  the  patient  did 
not  die  from  hemorrhage. 

Pulsation  in  tumor  ceased  imme- 
diately ;  cure  rapid. 

Tumor  began  to  decline  ;  pain  in 
head  ;  hemiplegia  ;  death. 

This  ancient  Gazette  boasts  that 
this  is  "  the  first  opera.tion  of 
this  magnitude  west  of  the  Al- 
leghanies."  (The  claim  is  well 
founded.) 

After  operation,  ringing  in  ears, 
difficult  deglutition,  somno- 
lence. Autopsy:  Softening  left 
hemisphere,  middle  lobe;  tu- 
bercle in  lungs  and  peritoneum. 

"After  operation  pain,  right  side, 
head." 


No  auiesthetic  ;  8th  day  erysip- 
elas :  rigors  on  62d.  Autopsy: 
Left  hemisphere  softened. 

Partial  paralysis  right  side  after 
operation  disappeared  ;  cough; 
dyspuoea,  etc.:  no  anasthetic ; 
end  2d  month  cure  coujplete. 

Peculiar  sensation  in  right  arm 
and  leg  after  operation  :  tumor 
suppurated  and  was  punctured. 


36 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Barileleben, 

lS-19. 

Bardeleben, 
lSo4. 

Bardpleben, 

.1S6B. 

Bardeleben, 

1874-5. 


Barovero,  1825. 


Barrier,  1847. 


Batchelder, 
1825. 

Baudens,  1 855 

(Crimean  w.<r;. 

do. 

do. 

Bauer,  1856. 


Bectou,  1827. 
Bedor,  1835. 

Beeby,  1861. 

Begin. 

Beck. 

Bell,  Jos. 

(Edinburgh). 

Bell  (England) 

1867. 

Bentley,  E. 

Bentlpy,  E., 
IS'Jl. 

do. 

Benedict,  1833. 
Benoit,  1852. 

Bei'uavd. 
Bernard,  1833. 

Bertherand, 

1851. 

Bertherand, 

1880. 

Beyer,  1846. 


Source  of 
information. 


Cause  of 
operation. 


Arch.  Klin.  Chir. 
do. 

do. 

Wiea.  Mediz.  Wochen. 
1875,  p.  33. 

Arcb.  Klin.  Chir. 


Gaz.  MeJ.,  1848.  p. 
774;  Arcb.  Klin.  Chir. 

Prof.  Jas.  R.  Wood,  in 

N.  Y.  Med.  Jr.,  July, 

1857. 

Arch.  Klin.  Chir. 

do. 

do. 

Ehrmann,  des  effets 

sur  rencepii.  etc.. 

Arch.  Klin   Chir., 

1868. 
IJorris  Conirib.  cit. 

do. 


Med.  Times  &  Gaz., 
Nov.  19,  1864,  p.  541. 

Arch.  Klin.  Chir.  cit. 

Schmidt  Jahrbuch., 

No.  150,  p.  307. 
Schmidt  Jahrbuch., 

No.  135,  p.  203. 
New  York  Med.  Jr., 

1869. 
Med.  Surg.  Hist.  Reb, 

do. 


Arcli.  Klin.  Chir. 

do. 

Schmidt  Jabrb.,  B 

15  J,  S.200. 

Gaz.  Med,  18.33;  Arch. 

Klin.  Chir. 

Ehrmann,  des  effets 

do. 


Arch.  Klin.  Chir. 


Mid 
age 


4^ 
mos 


Carles  of  parietal 
bone  and  hemor- 
rhage. 

Removed  tumor, 
parotid  (cancer). 

Removed  tumor 
of  neck. 

Traumatic  aneu- 
rism of  middle 
meningeal. 


Fung,     tumor     of 
palate. 


Traumatic  aneu- 
rism of  temporal 
artery. 

Osteo-sarcoma  of 
inf.  maxilla;  re 
moval. 

Hera 'go;  wounded 
soldier. 

do. 
do. 

Removed  tumorof 
neck. 


Epilepsy. 

Hemorr'ge ;  punc 
turein  neck  with 
awl. 

Hemor'ge  ;  cancer 
of  glandsof  neck 

Hemorrhage. 

Removed  tumor  of 
neck  (cancer) 

Traum.  aneur.  of 
left  orbit. 

Traum.  aneur.  of 
orbit. 

Wound  of  middle 
meningeal. 

Shot  wound  of  int. 
jugular  vein  and 
com.  carotid. 

Shot  w'd  of  head 


Aneur.  carotid. 

Aneur.    of   facial 

artery. 
Hem.;  phagedenic 

ulceration. 
Aneur.     anast. 

near  ear. 
Shot  wound  facial 

artery. 
Erecc.  tum  ,  temp 

region. 


R.    W'd  of  neck,  high 
up. 


2  years. 


9  years 


5  days. 


8  years, 


11  days, 


May  10. 


May  15. 


4,  7,  10 
days. 


THE    COMMON    CAROTID    AltTEIiY. 


37 


Common  Carotid  ylr/ery— coutiniied. 


Piitn  of 
operation 


j-3   P< 


a^i 


Kecovoiy.     Condition. 


Cause  of  death, 
date  after  op. 


Sept.  IT), 
1S43. 

April  G, 
1S.J4. 

May  27, 

1  S6(). 
1874-.')  ? 


Sept.  17, 

1825. 


Nov.  3, 
1847. 


June  26, 
1S25. 


do. 
do. 


March  21, 

1827. 
April  24, 

1835. 

July  9,  1864. 


May  15, 
1864. 

Junes,  1864 


June  24, 
1S:33. 


6tli  day, 
5th  day 


March  26, 

1S:«. 

June  2S, 

1834. 


Rocovurod. 


Eecovered. 
Recovered. 


Eecovered. 


Recoveied. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 
Recovered. 
Recovered. 
Recovered. 
Recovered 

Recovered 


Cured. 


0th  day;  pyajinia; 
pneumonia :  ab- 
BCCHH  of  brain. 


Cured. 
Cured. 


(Doubtful.) 
Cured. 


Cured. 
Cured. 


Cured. 
Cured. 
Cured. 
Cured. 
Cured. 


2  months  ;  encepha- 
litis; gastric  fever. 


Died. 


DiPd. 
Died. 


12th   day  ;    cerebral 

softeuinif. 


Few  weeks;  cancer. 


loth  day  ;  pyaemia. 
6th  day  ;  hem. 


6th  day  ;  heai.  and 
shock. 


SymptomH  of  paralyKiH  followed 
ofieration,  but  diHajijicared  in  a 
few  days. 

On  account  of  bemo'rliafce  dur- 
ini;  removal,  carotid  tied;  hemi- 
plegia .Cth  day. 

Headache,  dyHpnoea;  hemiple- 
gia .'id  to  7th  day. 

Carbolizod  catgut;  pulsation  tu- 
mor ceased  after  operation  ; 
hole  through  parietal  bone  ero- 
ded by  tumor,  covered  with 
plato. 

Symptoms  of  paralyses  after  op- 
eration. Autopsy:  iDllammation 
of  brain,  pus  in  right  hemi- 
sphere; inferior  jugular  vein 
tied  in  same  liga  urc  with  ar- 
tery. 


Cause  of  death  not  stated. 

Cause  of  death  not  stated. 
Cause  of  death  not  stated. 
No  cerebral  symptoms. 


"  Condition  unchanged." 

Cerebral  symptoms  fillowed  for 
a  few  days  after  operation. 

"Left  hemiplegia  on  10th  day. 
Autopsy  •  Hypframin  of  brain 
SAMR  si'ip.  of  ligaturi-." 

Difficult  deglutition  and  restless- 
ness after  operation. 


Ball  entered  near  occipiral  pro^ 
tuberance,  out  right  auditory 
meatais. 

Pulsation  returned  in  tumor.. 
Headache  after  operation. 

Electio-puncture  had  been  tried. 


No  cerebral  symptoms. 

Cerebral  trouble  followed, 

Ext.  carotid  tied  first .'  as  tumoT 
was  not  affected,  the  carotid 
(common)  was  tied  aud  the  first 
ligature  removed.  No  ceretiral. 
symptoms  followed. 


38 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


Billroth, 


do. 
Boeck,  1S55. 

Boeckel,  1861. 


Boilean,  1822. 

Boekenheimer, 

ISBo. 

Bonet,  1823. 

Bojanus. 
Bontecou,  1862. 


Boiayer,  1860. 
Bowker,  1872. 

Bowman,  1859. 
Bowman,  1860. 

Bos. 
Buck,  Gurdon, 

1S39. 
Buck,  Gurdon, 

18-12. 
Buck,  Gurdon, 

1818. 


Buck,  Gurdon, 

18o2. 
f    Buck,  Gur- 
I       don,  1857. 


Buck,  Gur- 
don, 18.59. 
Bunger,  1824. 

Busch,  lS6,i. 


Busch,  1819. 
Busli,  1827. 


Busbe,  1830. 


Schmidt  Jahrh.,  B. 

141,  S.  87. 
Dr.  Ch.  Pilz,  in  Lan- 
genbeck's  Archives. 


do. 
do. 


do. 


Schmidt,  B.  169,  S.  161 


Ehrmann,  des  effets  ; 
Arch.  Klin.  Chir. 
Arch.  Klin.  Chir. 

do. 

do. 
Med.  Surg.  Hist.  Reb. 


Arch.  Klin.  Chir. 
Lancet,  Oct.  11,  1873. 


Med.  Times  &  Gaz., 

1860. 

Arch.  Klin.  Chir. 

Norris  Contrib. 

N..  Y.  Med.  Jr.,  July, 

1857. 

do. 

do. 


N.  Y.  Med.  Jr., 
March,  1869. 

do. 

Arch.  Klin.  Chir. 

do. 

do. 
Norris  Contrib. 


Mid 
age 


Caiise  of 
operation. 


%-. 

rt  6 

o  o 

o  !>. 

■^  ^ 

rt  ji 

s.  s 

3 

•5.SP 
^■3 

5.2 

(=1 

■TJ 

=5  o 

p  a 


R. 


Aneur.  com.  caro 
tid,  high  up. 

Hem.  of  int.  caro 
tid. 


do. 

Hemorrh'ge  ;  stab 
mouth,  piece  of 
wood. 

Hemorrhage. 


Wound  of  throat 
piece  of  glass 
(ext.  carotid  and 
sup.  thyroid). 

Knife  wound  of 
neck. 

Hem.;  cancer. 

Hem.;  abscess  in 
neck. 

Nasal  polypus. 
Shot  w'd  of  face. 


1  year. 


Removed    tumor 

parotid. 
Hem.;  aneur.;  ext, 

carotid. 

Traum.  aneur.  of 
orbit.  , 

Spont.  aneur.;  or- 
bit. 

Tumor  of  Diploe. 

Encepli.  tumor ; 
parietal  bone. 

Suicidal  cut-thr't. 

Lacerated  (glass) 
wound  of  angle 
of  jaw. 

W'd  of  ext.  caro 
tid  or  branches. 

Traum.  aneur.  of 
right  orbit. 


Suicidal  wonnd  of 

neck. 
Hem.  ;  mouth  ;  in 

typhus  fever. 

Aneur.  anast.  of 
head  and  face. 

Aneur.;  com.  caro- 
tid, low  down. 


Erect,    tumor    of  19  y'rs. 
cheek. 


5  mos. 


20  mos. 

11  days 
5  days. 


14  days 


Above 
omo- 
hyoid. 


May  5. 


June  28. 
July  4. 


3  or  4 

days. 


May  16. 


Often. 


THE    COMMON    CAROTID    ARTERY. 


39 


Common  Carotid  Artery — continued. 


Date  of 
oporatiou. 


o  :^  o) 
QJ  o  c3 


Recovery. 


Condition. 


Cause  of  death, 
date  after  op. 


REMARKS. 


Doc.  1.3, 

ise4. 


Doc.'26, 
J       180-1. 
Dec.  1SJ5. 


Often. 


3d  day, 


Nov.  U, 
1861. 


Dec.  14, 
18(Jy. 

Sept.  U, 
1823. 


May  16, 
18G6. 


June  13, 
1860. 


7th  day. 


Feb.  28, 

1859. 
June  18, 

1860. 


10,  11, 
12  day. 


Dec.  21, 

18.S9. 

July  9, 1842, 

July  9, 1848, 


May  10, 
18.52. 
Dee.  22, 
18o7. 


After. 
63  day. 

2  hours, 

71  day. 


Feb.  23, 

18)9 

Feb.  19, 

1824. 

Nov.  23, 

1S6j. 

May  10, 

ism. 

Sept.  11, 
1827. 


Jan.  15, 

1830. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 
Recovered. 
Recovered. 


Recovered. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Recovered. 


Cured. 


3  days  after  last  op. 
liom.  and  cerebral 
exhaustion. 


2d  day,  exhaustion. 


3d  day,  coma. 


Cured. 


44   days  ;    cerebi-al 
complications. 


Cured. 


Not  cured. 
Cured. 


Not  cured. 


Cured,  with 

loss  of  eye 

Cured. 


Improved. 
Cured  ? 


13th  day,  pyajmia. 
7th  day,  hem. 


Several  days  coma. 


17th  day,  hem. 


Diai'rhcea  and  hem 


11th  day,  pysemia. 


2d  day ;  cerebral 
symptoms  and  ex 
haustion. 


Carbollzod  catgut. 

Had  had  Hyphilia.  Hemorrhage 
and  suppuration  from  ear»  r«- 
poatodly.  No  cerebral  symp- 
toms followed  first  op.,  loss  of 
coiisciousncHs  after  second. 


No  anajsthesia. 


Ext.  carotid  had  been  previously 
tied.  Autopsy:  Inflammation  of 
dura  mater.  Internal  carotid ' 
also  tied,  paralysis. 


Slight  braiu  trouble. 


Ball  enterpd  left  side  of  chin, 
broke  jaw,  carried  several  teeih 
away,  part  of  tongue  and  pha- 
rynx ;  fractured  transverse  pro- 
cess 3d  cervical,  against  which 
vrttbrnl  artery  had  cut  itself 
through  causing  fatal  hemor- 
rhage. 


Permanent    paralysis    of   sixth 
nerve. 

Died  11  months  of  hemorrhage 
and  disease. 


Hem.  on  71st  day,  ceased  spon- 
taneously. Int.  carotid  tied. 
Facial  paralysis  persistent  and 
complete.     (Due  to  injury.) 

Int.  carotid  also  tied. 

Fell  from  mast  striking  on  feet. 
5  mos.  after  first  operation  no 
improvement.  S  mos.  later  left 
carotid  tied. 


Tumor  was  large  and  suffocation 
imminent.  27th  day  tnmor  di- 
minished one  half.  3  years  later 
well.     Bra.sdor. 


40 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


PATIENT. 

<! 

"2 

CO 

M. 

20 

E. 

M. 

42 

R. 

M. 

Mid 

age. 

L. 

r. 

32 

E. 

M. 

30 

E. 

M. 

15 

E. 

M. 

1.5 

L. 

M. 

30 

L. 

M. 

Mid 

E. 

M. 

age 
Mid 

E. 

M. 

age 
34 

L. 

F. 

17 

M. 

Mid 

age 

E. 

M. 

Mid 
age 

L. 

M. 

47 

L. 

F. 

40 

L. 

M. 

23 

L. 

F. 

22 

R. 

M. 

35 

E. 

M. 

26 

L. 

M. 

47 

E. 

F. 

R. 

M. 

Mid 

L. 

M. 

age. 

.0 

m's. 

R. 

M. 

56 

E. 

F. 

60 

E. 

Cause  of 
operation. 


79        Busk,  1836. 


Butcher,  1863. 

Byrd,  W.  A., 

1876. 

B jerk  en, 1807 
(Sweden). 

Blackman,1843. 

f    Blackman, 
I  1848. 


I  do. 

Blasius,  1831. 
Bliss,  D.  W., 

1S64. 
Bliss,  Z.  E., 

1862. 
Brainard,  D., 

18.52. 
Brae,  1841. 

Brett. 
Breed,  B.  B., 

1864. 

Brewer,  G.  G., 

1864. 

Bramblett,  1864 


Briddon,  C.  K. 

ISoS. 

Briggs,  W.  T., 

1871. 


Brown,  B.,  1848. 

Brown,  J.,  1817 

Brodie,  1816 
(Blagden). 

Broca,  18S6. 


Von  Bruns, 
1859. 

Von  Brnns, 

1866. 
Von  Bruns, 

1844. 
Bryaat,  Prof. 
Thos.,  1876. 


Caldwell,  1840, 


Med.  Chir.  Trans, 
vol.  xxii.  p.  124. 


.\rch   Klin   Chir. 

N.  Y.  Med.  Jr.,  Aug. 

1S76. 

Arch.  Klin.  Chir. 


Norris  Goutrib. 

Am.  Jr.  Med.  Sci., 
April,  1848,  p.  337. 

Arch.  Klin.  Chir. 

do. 

Med.  Surg.  Hist.  Eeb. 

do. 

Arch.  Klin.  Chir. 

do. 

Norris  Contrib. 

Med.  Suri?.  Hist.  Eeb. 


New  York  Med.  Eec. 
June,  1869. 


Letter  to  author. 

Nash.  Jr.  Med.  Suri?., 
Feb.  1874  ;  Dr.  Bowl- 
ing to  author. 

Am.  Jr.  Med.  Sci., 
Oct.  1854,  p.  415. 
Norris  Contrib. 

Med.  Chir.  Trans., 
vol.  viii.  p.  224. 

Arch.  Klin.  Chir. 


do. 

do. 

do. 

Am.  Jr.  Med.  Sci. 
April,  1877. 


Norris  Contrib. 


Aneur.  of  orbit. 


Aneur.  innom. 

Shot  w'd  of  ext. 
and  int.  carotid 
angle  of  jaw. 

Aneur.  branch  of 
ext.  carotid  be- 
hind ear. 

Fung,  tumor  of 
neck. 

Fungus  hsematod. 


do. 

Cancer  parotid. 

Shot  wound    inf 
maxilla. 

Shot     wound     of 
lingual  artery. 

Aneur.  anast.  or- 
bit. 

Shot  wound. 

Tumor  of  parotid. 

Shot  wound  right 
malar  and  inf. 
max. 

Shot  wound  neck 
and  cheek. 


Shot     wound 
cheek. 


of 


Malig.  turn,  orbit. 

Stab  wound  int. 
carotid  ;  aneur- 
ism. 

Epilepsy. 

Hem.;  cut-throat. 

Hem.;  extract,  of 
2d  molar  of  left 
upper  jaw. 

Hem.  of  carotid. 


Hem.  after  remov- 
ing thyroid  body. 

Second,  hem.  int. 
maxillary. 
Buccal  tumor. 

Aortic  aneur. 


Erect,  tum.  orbit. 


7  hours, 

8  years 

2  years, 
do. 

do. 


44  days 


4  mos. 
5  years. 


Some 

time. 

Several 

weeks. 


5  years. 
7  days. 
5  days. 

39  days. 


Some 
time. 


1  year. 


May  12, 
May  3. 


May  3] . 


Below 
omo- 
hyoid. 


Aug.  1. 


Aug.  29, 
30. 


Oct.  19, 
1864. 


10th 
day. 


Above 
omo- 
hyoid. 


Jan.  25, 
1871. 


Often. 


June 
;w. 


Often. 
Often. 


THE    COMMON    CAROTID    AKTEKY. 


41 


Common  Carotid  Artery — continued. 


No. 


Date  of 
opofation 


UKMAIUs'S. 


Feb.  2,  18:3{) 


.Inly  1.3,  18.3.'>,  Hti-uok  on  ho;nl  by 
(.'alf.  Hem.  iiiiinodiato,  rij^ht 
oar.  .Tuly  28,  jiain  in  Icl't  oyi;. 
Sept.  .'i,  ulceration  cornea.  Feb. 
1,  aneurism  evident.  PreHHure 
on  left  carotid  arrested  pulsa- 
tion. Loss  of  vision  left  eye 
after  recovery.     Braador, 


16  years   after  tumor  began   to 
grow  agaiu. 


Nov.  9, 
1864. 


Dec.  1864. 


July  7, 1858. 


Feb.  23, 

1871. 


June  14, 

1817. 
July  5, 

1816. 

March  26, 
1866. 

July  11, 
lSo9. 


1876. 


Sept.  16, 
1840. 


5  min- 
utes. 

13  days. 
Often. 


Recovered, 


Recovered, 
Recovered, 


Recovered, 
Recovered, 


39       Recovered. 


Cured. 
Cured. 


12th  day;    cerebral! 
symptoms. 


1870  reported  "disability  J  and 
permanent." 


Ball  entered  back  of  neck  (left 
side)  and  passed  out  through 
cheek. 

10th  day  after  wound.,  internal 
carotid  tied.  Hem.  followed, 
and  common  and  external  caro- 
tid secured.  Hem.  still,  arrest- 
ed by  styptic. 


Cured. 
Cured. 


Cured. 


2   days ;    hem.    and 
exhaustion. 

27  days. 


9  days ;    abscess   of 
right  hem.  ;  coma 
hemoi-rhage. 


10th  day. 


Com.  carotid  tied  first ;  hem.  did 
not  cease  ;  sac  opened  and  buth 
ends  of  internal  carotid  tied.  No 
cerebral  symptoms  followed. 

Well  in  18.53. 


Hemorrhage  after  op.  from  tooth 
and  wound  of  op.  Memorrliogic 
diathesi.i. 

Cavern  in  right  lung.  Hem. 
(General  bad  condition  may  ac- 
count for  death.) 

Autopsy.     (See  cause  of  death.) 


Autopsy:  Ascending  and  trans- 
verse arch  of  aorta  enormously 
enlarged.  Right  jugular  vein, 
right  carotid,  and  subclavian 
artery  occluded.  Distal;  War- 
drop. 


42 


PEIZE    ESSAY. 


Surgical  History  of  the 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 
(=1  o 

o  o 

It 

< 

6 

"^  1 
j3 

lOfi 

Campbell,  1845. 

Cantrell,  J.  Y., 
1862. 
Carnoohan, 
New  York. 

[           do. 
Carpul. 

De  Castro,  1864. 

Catolllca, 

Caltolica  ? 

Cockle,  John, 

1872? 

Coe,  1851. 

Coates,  1816. 

Cogswell,  1803. 
Cole,  1815. 

Collier,  1815. 

Colson,  1839. 

Cooper,  A.,  1805. 

do.        18CS. 

Cooper,  B.,  1840. 
do. 

Coote,  H.,  18.58. 

do.        1860. 

Curling,  T.  B., 

lfc.-54. 

Curtis,  1S57. 

Cusack,  1820. 

do.      1836. 
Cuveiller,1860. 

Cbadwick. 

Chapel. 

Arch.  Klin.  Chir. 

Med.  Snrg.Hist.  Reb. 

Am.  Jr.  Med.  Sci., 
July,  1867. 

do. 
Arch.  Klin.  Chir., 

B.  ix. 
Arch.  Klin.  Chir., 

B.  xvii. 
Arch.  Klin.  Chir., 

B.  ix. 

Am.  Jr.  Med.  Sci., 

April,  1873. 

Letter  from  Prof.  Paul 
F.  Eve  to  author  ; 
Arch.  Klin.  Chir. 

Norris  Contrib.;  Arch. 

Norris  Contrib. 
Arch.  Klin.  Chir. 

Norris  Contrib. 

Norris  Contrib.; 

Arch.  Klin.  Chir. 

Med.  Chir.  Trans., 

vol.  i. 

Med.  Chir.  Trans., 
vol.  i.  p.  224. 

Norris  Contrib. 

Lancet,  1846,  vol.  i. 
p.  134. 

London  Med.  Times  & 
Gaz..  vol.  i.  1858. 
Arch.  Klin.  Chir. 

Med.  Chir.  Trans., 
vol.  xxxvii.  p.  221. 
Am.  Jr.  Med.  Sci., 
1861. 
Norris  Contrib.; 
Arch.  Klin.  Chir. 

Dub.  Med.  Jr.,  Feb. 

1847,  p.  262. 

Poland  in  Guy's  Hosp. 

Eep.,  vol.  XV.  1870. 

Lancet,  1851,  vol.  i. 
p.  177. 

Arch.  Klin.  Chir. 

M. 

M. 
F. 

F. 

48 

Mid 

age. 

34 

34 

E. 

R. 
L. 

107 

of  innominate. 

Shot  wound  neck, 

near  larynx. 
Elephantiasis 

Grsecorum. 

do. 
Hemorrhage. 

Aneur.  of  ext'rnal 

carotid. 
Traum.  aneur.  of 

vertebral. 
Aneur.   ascend. 

aorta. 

Traum.  aneur.  of 
carotid. 

Aneur.     of     com. 
carotid. 

Turn,  of  parotid. 

Shot  wound. 

Hem.  of  wound  of 
angle  of  jaw. 

May  8. 

May  15. 

TOS 

109 

no 

m 

M. 
M. 
M. 

F. 

M. 

F. 
M. 

M. 
F. 
F. 

M. 

M. 
M. 

M. 
M. 
M. 
M. 
M. 

M. 
M. 

M. 

31 

48 

55 
41 

37 

27 
63 
44 

60 
34 

64 
46 
49 

36 

20 
24 

13 

R. 
L. 
L. 

L. 

L. 

L. 
L. 

L. 

L 
R. 

L. 
R. 

R. 
L. 
R. 
E. 
L. 

L. 
R. 

E. 

15  mos. 

1T^ 

n?! 

1U 

5  mos. 

6  mos. 
do. 

115 

iifi 

117 

IS 

5  days. 

IP 

1?0 

do. 

Aneur.   int.  caro- 
tid. 

Aneur.  com.  caro- 
tid. 

Hem.;  suicidal 
cut- throat. 

Fung,    growth   of 

right  sup.  max. 
Hem.;  removed 

sup.  maxilla. 
Aneur.    of    orbit; 

traum. 
Shot     wound     of 

mouth. 
Hem.;    wound    of 

throat. 

Aneur.  of  carotid ; 

traum. 
Aneur.  subclav.; 

bayonet  wound. 

Lacerated     scalp 
by  circular  saw  ; 
hem. 

Aneur.  carotid. 

5  mos. 

6  mos. 
1  year. 

T^l 

19^ 

777) 

ns 

1?4 

Aug. 18. 

1W 

1?fi 

2  w'ks. 

19,7 

1?,S 

l-Jfl 

2  mos. 
12  days. 

Below 
omo- 
hyoid. 

ISO 

131 

THE    COMMON    CAROTID    ARTERY. 


Common  Carotid  Artery — continued. 


Date  of 
operation. 


March  8, 
184,j. 


Jan.  .3,1816, 


Nov.  14, 
1803. 

June  28, 
1815. 


June  22, 
ISlf). 
1839. 

Nov.  1, 
ISOJ. 


June  22, 

1808. 


April  7, 
IS-iO. 


Aug.  22, 

1S(J6. 
June  2, 

]  8.H. 
April  19, 

18r;7. 
Aug.  16, 

1820. 


Nov.  22, 
1836. 
1860. 


3  days. 
Often. 


45-46, 
49-57 
dSys. 
Often. 


21  days. 


Often. 


32d  day. 


7th  Jay. 


s>^ 


14 
4? 

13 

28 

n 


.22 
and 
23 
33 


24 


Recovery,      Condition. 


Kecovercd 


Recovered. 
Recovered. 


Recovered. 


Recovered. 


Recovered. 
Recovered, 


Recovered. 


Recovered. 


Recovered. 
Recovered. 


Recovered. 


Recovered, 


Improved. 
Cured. 


Improved. 


Cured. 
(Improv'd.) 


Cured. 


Cured. 


Cured. 
Cured. 


Cured. 


Cured. 


Cause  of  death, 
date  after  op. 


19th  day,  fever,  de- 
lirium. 


43d   day,  hem.   and 
prostration. 
Hem.;  sac  burst. 


71st  day,  hem. 

20th  day,  hem. 
4th  day,  asphyxia. 


20tli  day,  inflam.  of 
sac. 


21st  day. 


3d  day,  hem.;  cere- 
bral exhaustion. 
2  hours,  exhaustion. 


60th  day,  hem. 


10th  day,  hem. 


Antdpsy;  Inflainmatiotj  lunt'H. 
Aneurism  of  arcli  of  aoria,  ('ar- 
otid  occluded.  Distal;  War- 
drop. 


"  6  months  after  1st  op.  improve- 
ment njarked.  8  yrars  later 
patient  was  quite  prcsentaljle  ; 
could  see,  hear,  smell,  and  taste 
well '." 


3d  day  sac  opened  and  external 
carotid  was  tied. 

AneiirisMi  located  on  vertebral 
artery.     Distal. 

12  months  after  op.  patient  was 
working  as  farm  labori-r.  (Ara 
uuable  to  say  whether  this  case 
is  identical  with  Mr.  Heath's  or 
not.) 


2  ligatures,  vessel  cut  between. 
Hyoid  bone  broken.  Severe  la- 
ceration. (Ligature  probably 
slipped  over  end  of  artery.) 
Pus  in  bronchi. 


Partial  paralysis  of  left  side.  2 
ligatures  ;  vessel  not  divided. 
Inflam.  of  sac  and  pressure  on 
larynx  caused  difficult  respira- 
tion. 


"  Died  from  mental  disturbance 
and  irritation  of  wound."  This 
case  not  numbered  by  mistake — 
numbered  at  the  last. 

Paralysis  resulted.  Autopsy: 
Right  hemisphere  softened. 


Cerebral     symptoms    followed, 
but  gradually  disappeared. 
No  cerebral  symptoms  followed. 

Sup.  thyroid  tied  ;  32d  day  after 
hem.  and  common  carotid  tied 
a  second  time.  Hemorrhage 
persisted. 


Right  subclavian  tied  same  time. 
Distal. 


I  Bones  of  skull  were  deeply  in- 
dented by  saw-teeth. 

4th     day,    cerebral  Autopsy:      Breaking    down    of 
softening.  1  brain  substance. 


44 


PRIZE    ESSAY. 


Su7'gical  History  of  the 


Nam-e  of 
operator. 


Source  of 
information. 


Cause  of 
operalion. 


-S  S 


Clieever,  1862. 

Chelius,  1836. 
Chaumet. 


Chassaiornac, 
1859'. 


Cherry,  1858. 
Cliesley,  1864. 
Chiari,  1829. 


Clark,  Le  Gros. 

18-16. 
Clark,  Le  Gros, 

1860 
Clarke,  W.  S., 

1855. 

Glaus,  1846. 
Cleary,  1864. 

Cline,  1808. 

Critchett,  1854. 

do.        1855. 

Crosby,  T.  R., 
1864. 


do. 

De  Cruz,  1825. 

Dalrymple, 

1813. 

Davidge,  1823. 

Davis,  R.,  1860. 

Debrou,  1867. 

Deces,  1839. 

do.     1850. 
Dehane,  1S32. 

Delpecli,  1831. 

Demme,  1859. 

do. 

Demme,  1840. 


do. 

Deguise,  1827. 

Delore,  1860. 

Despres 

(Sedan). 


Med.  Surg.  Hist.  Reb. 

Norris  Contrib. 
Arch.  Klin.  Chir. 


Traite  des  operations, 
p.  326. 


Ehrmann  des  effets. 

Med.  Surg.  Hist.  Reb. 

Norris  Contrib. 

do. 

Med.  Times  &  Gaz., 

1860,  vol.  1.  p.  190. 

Lancet,  1855,  vol.  ii. 

p.  165  ;  Arch.  Klin. 

■Chir. 

Arch.  Klin.  .Chir. 

Arch.  Klin.  Chir., 

vol.  xvii.  p.  626. 

Norris  Contrib. 

Arch.  Klin.  Chir., 

1868. 

Med.  Times  &  Gaz., 

lS.i5,  p.  437. 
Med.  Suvg.  Hist.  Reb, 


Norris  Contrib. 

Med.  Chir.  Trans., 

vol.  vi.  p.  111. 

Norris  Contrib. 

Ed.  Med.  Jr.,  Jan. 

1862,  p.  685. 

Schmidt,  B.  138,  S.  .53. 

Ehrmann  des  effets ; 
Arch.  Klin.  Chir. 

do. 
Am.  Jr.  .Vied.  Sci., 

vol.  X.  p.  496. 
Arch.  Klin.  Chir. 

Arch.  Klin.  Chir., 

vol.  ix.  and  xvii. 

do. 


do. 

Ehrmann  des  effets, 

Gaz.  des  Hop.,  1860. 

Gaz.  des  Hop.,  1871, 

p.  362. 


Shot  vround  of  left 
side  of  face. 

Aneur.  varix.  of 
temp,  region. 

Removed  cancer 
of  parotid. 

Hem.  after  punc- 
ture of  retro-pha- 
ryngeal  abscess  ; 
w'd  of  internal 
carotid. 

Erect,  tumor 
(fungus). 

Shot  wound  sup. 
max. 

Traum.  aneur.  of 
vertebral  artery. 

Wound  of  exter- 
nal carotid. 

Stab  w'd  of  neck 
(carving-knife). 

Aneur.  of  carotid 
(angle  of  jaw). 

Suicidal  cut-thr't. 
Shot  w'd  of  face. 


1  year. 


Above 
omo- 
hyoid. 


May  31. 


June 
13-14. 


Short 
time. 


1|  h'rs 
6  mos. 


R. 


Aneurism. 
Hem.;  abscess. 

Hem.;    aneur.    of 

orbit. 
Shot  w'd  through 

left  temporal 

bone. 


Same   vessel   tied 
again. 
Wound  of  throat. 

Erect,     tumor     of 

orbit. 

Fung,  of  antrum. 
Suicidal  cut-thr't; 

angle  of  jaw. 
Stab   in  neck 

(knife). 
Aneur.  of  carotid 

(traumatic), 
do. 
Aneur.,  traum. 


Few 
hours. 
1  year. 

lOiy'rs. 


Hem.  of  nose. 

Shot  wound  of 
temp,  artery. 

Shot  wound  inf. 
max.  (fracture). 

Aneur  of  carotid. 


54  days. 
35  days. 
25  days. 


Erect,  tumor. 
Aneur  of  carotid. 
Shot     wound      of 
face  and  neck. 


Sept.  30. 


Oct.  7. 


May  6. 


June  2 
and  20. 


Above 
omo- 
hyoid. 


Sept.  1. 


Sept.  9. 


THE    COMMON    CAROTID    AKTEUY. 


45 


Common  Carotid  Artery — continued. 


No. 


Diito  of 
operation. 


W  ° 

Recovery.      Condition, 


Cause  of  death, 
date  after  op. 


Kii.MAUKS. 


132 

133 
134 

135 

136 
137 
138 

139 

140 
141 

l42 
143 

144 

14.) 

146 

147 


148 

149 

1,50 

Inl 
152 

153 

154 

l.')5 
156 

157 

158 

159 

160 


161 
162 
]«3 
164 


Juno  14, 
1S02. 


.Tan.  IS, 
1836. 


Aug.  1859. 


Oct.  7.  1864. 


July  IS, 
18-9. 

Oc'.  14, 

18-16. 
Jan.  23, 

1860. 
July  2), 

1855. 

Dec.  31,  '46, 
Oct.  4,  1864, 

Dec.  16, 

1S08. 


June  20, 
1864. 


45  days 

later. 
Feb.  27, 

1825. 
April  7, 

1813. 
April,  1823, 

1860. 

1867. 

Feb.  2,5, 

1839. 

Sep.  2,  1850 

Jan.  20, 

1832. 

1831. 

1859. 


45tli 
day. 


8.1th 
day. 


None. 


Sept.  24, 
1840. 


Sept.  9. 


9,  11,  17 
days 


Recovered, 


Recovered. 


Recovered. 
Recovered 
Recovered. 


Recovered. 


Recovered 
Recovered. 


Recovered, 

Recovered, 

Recovered 

Recovered, 
Recovered 


Recovered, 
Recovered, 


Recovered. 


Cured. 


10th  day. 


8th  day. 


5th  day. 
9th  day. 


Cured. 

Cured. 

Cured.  (7) 


Cured. 


Cured  ;  loss 
of  eye. 


Cured. 

Cured. 

Improved. 

Cured, 
Cured.  (?) 


Cured. 
Cured. 


Artery  tied  3  times  in  succfSHion 

before  hemorr'ge  wan  arr'-Hted. 

Cerebral  symiitoms  on  2d  day. 
Hem,  profuse   before  op.  :  after 

op.  aphonia   and  headache  for 

24  hours. 


Autopsy:  Aneurismal  of  vfrte- 
bral  artery  between  1st  and  2d 
cervical.     Wardrop. 


Autopsy:  Thrombus  in  carotid. 
Ext.  carotid  tied  14  days  after 
injury.     Common  carotid  33. 


3d  day.     Glossitis. 
2d  day. 

4th  day.     Hem. 


3d  day.  Exhaustion 

4  or 5 months.  Hem. 'No  cerebral  symptoms. 


6  weeks.     Tetanus. 


10th  day. 


49th  day.    Pysem. 
Exhaustion. 


Died.  (7) 

49th  day.     Hem. 

5th  day.     Coma. 


Ball  entered  over  left  ear:  open- 
ing large  as  two  fingers  ;  out  3 
inches  anterior ;  duramaternot 
opened.  May  17,  headache; 
20th,  comatose  ;  June  2,  hem.  ; 
June  20,  ligature  ;  45  days  later 
hem.  ;  common  carotid  tied 
again. 


2  ligatures,  artery   divided  be- 
tween. 

Carotid  tied  between  two  ten- 
dons of  origin  of  sterno-mastoid. 
Headache  as  a  sequel. 


"Very  much  improved." 

Autopsy  :    Pus  at  base  of  brain  ; 
inflam.  internal  jugular  vein. 


Cerebral  symptoms  5  days  after 
op. ;  relieved  by  venesection. 
Autopsy:  Pus  in  sac  and  in  tis- 
sues near  wound. 


Facial  paralysis  2d  day  after  op. 
(left)  ;  3d  day  paralysis  body 
on  left  side. 


46 


PRIZE    ESSAY. 


Surgical  History  of  the 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 

o 

0.2 
.3  bo 

o  -^ 

^  bD 

6 

bo 

< 

Ti 
m 

operation. 

1fi5 

Despres 

(Sedan). 

do. 

Dewar,  1860. 

Detmold,  Prof. 
Wm.,  1840. 

Detmold,  Prof. 

Wm.,  1842. 
Detmold,  Prof. 

Wm.,  1845. 
Detmold,  Prof. 

Wm.,  1847. 
Detmold,  Prof. 

Wm.,     ? 
Dieffenbacli,'28. 

Dletrich.son. 
DolillLoff,  1837. 

do. 

Donaglie,  1856. 
Dudley,  1841. 
Duffin,  1823.  ? 

Duke,  1847. 

Duncan,  1836. 
do.       1843. 

Dupont,  1814. 
Dupuytren 

1814. 
Dupuytren, 

1818. 

do. 

Dupuytren, 

1835. 
Drop.sy,  1855 
(Burnoth).  ? 
Dzondi,  1824. 

do.      1825. 

Doughty,  P.  E., 
1875. 

Gaz.  des  Hop.,  1871, 

p.  362. 

do. 

Med.  Times  &  Gaz., 

1860,  vol.  i.  p.  90. 
Personally  to  author. 

do. 
do. 
do. 
do. 

Arch.  Klin.  Chir. 

do. 

Eust.  Mai?.,  1838; 

Ehrmann  des  effets. 

do. 

Prof.  Jas.  E.  Wood  in 

N.  Y.  Med.  Jr.,  1857. 

Norris  Contrib. 

Lancet,  1823,  vol.  ii, 
p.  200. 

Lancet,  1848.  vol.  i. 
p.  233. 

Norris  Contrib.; 

Arch.  Klin.  Chir. 

Ediu.  Med.  &  Surg. 

Jr.,  1S44,  vol.  Ixii.  p. 

117. 

Norris  Contrib. 

Norris  Contrib.; 

Arch.  Klin.  Chir. 

Ehrmann  des  eifets  ; 

Arch.  Klin.  Chir. 

Norris  Contrib. 

Arch.  Klin.  Chir. 

Arch.  Klin.  Chir. 

Ehrmann  des  effets. 

Arch.  Klin.  Chir. 

do. 

Prof.  Alex.  B.  Mott  to 
author. 

M. 
M. 

P. 
F. 

M. 

F. 

M. 

M. 
F. 
M. 

F. 

F. 
M. 
F. 

M. 

M. 
F. 

M. 
M. 

F. 

M. 
M. 
F. 
M. 
F. 
M. 

Ififi 

and  int.  carotid, 
do. 

Hem.;     pulsating 
tumor  of  tonsil. 

Vase,     tumor     of 
right  side  head. 

Vase,  tumor  chin. 

Aneur  ;  anast.  of 

left  ear 
Malig.   tumor   (to 

arrest  growth). 
Eemoved  sup. 

max.;  malig.  dis. 
Fung,  of  parotid. 
Hem.  of  tumor. 

167 

27 
26 

8 
mos 
40 

R. 
R. 

L. 
L. 
E. 

168 

169 

170 

171 

172 

173 

3 

25 
49 

51 
15 

4 
32 

60 
30 

27 
42 

76 

20 
18 
25 
60 
25 
45? 

R.' 
E. 

E. 

E. 
E. 
R. 

R. 

L. 
E. 

L. 
E. 

L. 

E. 
L. 
L. 
E. 
L. 
E. 

174 

17,1 

176 

palate. 
Aneur.,  innom. 

Cancerous    tumor 
of  mouth. 

Erect,    tumor     of 
orbit. 

Hem  of  facial  ar- 
tery. 

Traum.  aneur.  of 
carotid;  pharynx 
(supposed  abso.) 

Hem.;     ulcer     of 

throat. 
Aneur.  of  carotid 

at  bifurcation. 

Aneur.  of  carotid. 
Shot  vp-'d  of  ext. 

carotid  and  facial 
Aneur.  of  internal 

carotid. 

Erect,     tumor    of 
ear  and  temple. 

Enceph.  tumor  of 
temp,  region. 

Aneur.  of  carotid, 
traum. 

Hem.;    cancer    of 
tongue. 

Eemoved  inferior 
maxilla. 

Aneur.;     root     of 
neck      (probably 
at  bifurcation  of 
innominate). 

177 

178 

Several 
years. 

179 

ISO 

1  year. 

181 

182 

1S.S 

6  mos. 
22  days. 

184 

185 

186 

187 

15  mos. 
1  year. 

188 

189 

190 

191 

THE     COMMON    CAROTID    AHTEHY. 


47 


Common  Carotid  Artery — continued. 


Date  of 
oporatioii. 


1^   s3^ 


Bocovery. 


Condition. 


Cause  of  deatli, 
date  after  op. 


After. 
do. 


.Tnno  2, 
1S40. 


1842. 
1845. 
1847. 


1828. 

May6,'is37l 

1837. 

1856. 

Jan.  1841. 

1S23  ? 


Jxiue  10, 
1S47. 


Marcli  29, 

1836. 

Dec.  25, 

1843. 

1814. 

Feb.  24, 

1814. 

1818. 


April  8, 

1818. 
Jan.  1835. 

June,  1855  ? 

1824. 

July  8, 1825 

Nov.  1,1875 


7tliday. 


After. 


4,  10,  1] 
days. 
1.5tli 
day. 


None. 


Recovered. 
Recovered. 

Recovered. 
Recovered. 
Recovered. 


No  improve- 
ment. 


Cured. 
Cured. 


(Growth 
checked. ) 


Recovered 


Cured. 


Recovered. 
Recovered. 


Arrested 

tempor'rily. 

Cured. 


Recovered. 


Cured. 


Recovered. 


Recovered. 


Recovered. 


Improved. 


Few  minutes.  Hem.  Fatal    hemorrhage  from   distal 

end. 

do.  do.  i"  I/'li'morrhagie  etait  tellement 

j  foiidri)yaiiti'  riue  j'ai  en  a  peino 

I  lo  lemjis  do  decou vrir  I'artere." 

Syjiliiiitic  diathesis. 

"  Op.  made  no  impression  on  ta- 
moi- ;  died  18  months  later  of 
plitliisis." 

"After  ligature  tumor  laid  open 
and  hot  iron  applied." 


Died  6  months  later  from  disease. 


4th  day. 

14th  day,  of  dis. 

26th  day.     Cerebral  8th  day  after  op.  left  paralysis, 
softening.  i  Autopsy:    Brain  softened. 

5th   day.     Cerebral  3d  day  left  paralysis.    Autopsy: 


complications. 


Few  hours. 


5  weeks.    Hem. 


Caries  of  clavicle  ;  hyperjemia 
of  braiu. 

'  Died  4  months  later  exhausted 
by  disease." 


''Hem.  ceased  after  op.  Autop- 
sy :  Ulceration  of  submaxillary 
gland." 

Paralysis  after  op.  slight.  (Dr. 
Duke  did  not  puncture  the 
aneurism  by  mistake,  but  was 
called  in  to  tie  the  carotid. — 
Author.) 

13th  day.    Bronchi-Hem.  central  end  of  artery;  pe- 
tis  and  hemorrhge.!  ripheral  end  was  occluded. 
17th  day.  Hem.  and  Tracheotomy  was  performed  be- 


spasm  of  glottis. 


6th  day. 

Sth   day.     Cerebral 
complications. 


loth  day.     Original 
disease. 


5th  day.     Cerebral 
comp.  and  disease. 

ISth   day.      Brain 
symptoms. 


fore  operation.     Autopsy:    Sac 
had  burst  into  trachea. 


After  op.  cough,  difficult  deglu- 
tition, and  general  insensibil- 
ity. Autopsy:  No  appreciable 
change  in  cerebrum. 


3d  day  paralysis  of  left  side. 

Autopsy:  Softening  of  cerebrum. 

This  patient  was  operated  upon 
by  Prof.  A.  B.  Jlott  one  year 
after  the  above  date,  and  the 
subclavian  was  tied  in  its  3d 
division.  The  author  saw  this 
man,  by  invitation  of  Prof. 
JMott,  one  year  after  the  latter 
had  tied  the  subclavian,  when 
he  was  almost  entirely  recover- 
ed. A  small  tumor  about  the 
size  of  an  almond,  and  quite 
hard,  could  be  felt  just  b'^hiud 
the  steruo-clavicular  articula- 
tion. Patient  told  nie  he  was 
quite  weak  in  his  Uff  arm  for 
some  time  after  the  carotid  was 
tied.    Distal. 


48 


PRIZE    ESSAY. 


Surgical  History  of  the 


No. 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


192 
193 
194 


Eastman,  1S73, 

Buffalo. 

Eccles,  1843. 


Ehrmann,  A., 
1858. 


Eliot,  J.,  1876. 


197 

19S 


199 
2D0 


232 
203 
204 

20  iJ 
205 
206 
207 


209 
210 

211 
212 


f    Ellis,  1844. 

\  do. 

I 

Ellis,  183). 

Ensor,  1S74, 
Africa. 

Esmarch,  1857. 

Evan,  Thomas? 

Evans,  1828. 

Eves,  A.,  1847. 


Eve,  Prof.  Paul 

F.,  see  Z  at  end. 

Ewing. 

Fairfax,  1842. 

Fearn,  S.  W., 
1847. 

Fearn,  S.  W., 
183j. 


Fergusson, 
1S41. 

Field,  1858. 

Von  Fillen- 
baum,  1872. 


Loud.  Med.  Gaz.,  1S32, 

vol.  ix.  p.  374. 

Letter  from  Prof.  J.  F. 

Miner  to  author. 

Norris  Contrib. 


J.  Ehrmann  des 
effets,  etc. 


Am.  Jr.  Med.  Sci. 
April,  1877. 


Ehrmann  des  effets  ; 

Arch.  Klin.  Chir. 

do. 

Norris  Contrib. 

Lancet,  187.^  ;  Am   Jr. 

Med.  Sci.,  1875. 


Arch.  Klin,  Chir. 


Lancet,  1853,  vol.  ii. 

p.  225. 
Ehrmann  des  effets  ; 

Norris  Contrib. 
Lancet,  1849,  vol.  i. 

p.  556. 


Norris  Contrib. 

do. 

Ehrmann  des  effets; 
Arch.  Klin.  Chir. 

Ehrmann  des  effets  ; 
Arch.  Klin.  Chir.; 

Norris  Contrib. 
Arch.  Klin.  Chir. 

Arch.  Kliu.  Chir.; 
Norris  Contrib. 

Med.  Times  &  Gaz., 

1S58,  vol.  ii.  p.  217. 

Schmidt  Jahr.,  B.  156, 

S.  199. 


Schmidt  Jahr.,  B.  156, 

S.  193  ;  Wieu.  Mediz. 

Woch.,  1872,  p.  29. 


20 


Mid 
age. 


L. 


E. 


Removed  sup. 
maxilla. 
Aneurism. 

Tumor    (sup. 
aneurism). 


Aneur.     of    ext. 
carotid  (traum.). 


2  years. 


Aneur.  of  innom. 


Shot  w'd  tongue. 

do. 

Wound  of  thi'oat. 
Aneur.  of  aorta 
and  innom. 


Removed  tumor  of 
throat. 

Hem.;  opening 
abscess  of  scalp. 

Aneur.  of  innom. 
and  carotid. 

Suicidal  cut-thr't; 
angle  of  jaw. 


Removed  tumor  of 
neck. 
Aneurism. 

Stab  ;  int.  carotid. 


Aneur.,  innom. 


Shot  wound  facial 

artery. 
Aneur.,  innom. 

and  subclavian. 

Hem.;   removed 
sup.  maxilla. 

Shot  w'd  of  neck 
and  face. 


Pistol  w'd  of  face 
wound  inter. 
max.  art. 


7  days. 
11  days. 

8  days. 


Below 
omo- 
hyoid. 


About 
1  year. 
Short 
time. 


30  y'rs. 


Below 
omo- 
hyoid. 


At  omo- 
hyoid. 


2  years. 

2  days. 
12days. 


Few 
hours. 


Above 
omo- 
hyoid. 


June  15. 

1858. 


Aug.  10. 


Imme- 
diate, 
and  6th 
and  7th 
days. 


THE    COMMON    CAJtOTII)    AHTKHY. 
Common  Garolid  ^W«rv/— continued. 


49 


No. 


Pate  of 

oi'oratioii. 


■f  £'0 


192 
193 
194 


About  1873. 

Sept.  23, 
1843. 


"(^>, 


Oct.  l.'j, 
1876. 


1844. 

4  clays  la- 
ter. 
Jan.  26,  '3;5. 
Sep.  8, 1874. 


Aug.9, 1S57, 


lethi 
day. 


Recovery. 


Recovered 
(?) 


Recovered 


Condition. 


Cause  of  death, 
date  after  op. 


Pyaemia. 


July  22, 

1S2S. 

April  2, 

1847. 


Feb.  11, 

1832. 

July  18, 

1842. 

Feb.2, 1S17, 


Aug.  .30, 
1836. 


June  22, 
1841. 

June  17, 

1  S.iS. 
1872. 


Ausr.  17, 
1872. 


Once. 


Slight. 


Recovered. 
Recovered 
Recovered. 


Recovered. 

Recovered. 
Recovered. 
Recovered. 


20 


Next 
day. 


23-25 


Cured. 
Cured. 
Cured. 


RKMARKS. 


Patif-nt  was  doing  well  0  day« 
after  operation. 


Died  of  bron'hitiH  in  4  months. 

AiitopHy  Khowod  diseaKo  to  bo 

e.nlirge.d  gland. 

4th   day.     CerebraliFew  hours  after  op.  right  hr-mi- 

complicatious.  plegia,  hypora5sthe«ia  left  face  ; 

oxter,  strabismus  loft  eye.    Po- 

I  Hf.ntnn)e.r8p<ike.nft>'.ri)'i)i>.raVn. 

2.Tth  day.  Exhaust.;  Subclavian  tied  same  time.  (.See.) 


hemorrhage. 


Not  cured. 

Cured. 
Cured. 
Cured. 


65th  day.    Pleuritia 
and  hemorrhage. 


Recovered. 
Recovered 


Recovered. 


4th  day,  Exhaust'n 
5th  day.  Exhaust'n 
79th  day. 


Cured. 


Cured. 


7th    day.     Pleuro- 
pneumonia. 


8th  day. 


Oct,  31,  or  Ifith  day,  hem.  from 
sac  16  ounres.  Died  2.jth  day, 
loss  of  blood  in/ormir)^clot  in 
sac,  and  by  external  hem.  ;  to- 
tHl,  8  lbs.  3  ouiices  !  Body 
weighed  130  lbs.  Autop-y:  Lig. 
atuie  loose  in  wound  ;  floor  of 
arch  atheromatous  ;  opening  of 
innominate  2  inches  in  diame- 
ter ;  sac  5j  inches  verlif-aUy, 
transversely  4  inches,  antero- 
posteriorly  3^.     Distal. 


No  cerebral  symptoms  except 
dyspurea. 

No  cerebial  symptoms  noted. 

Patient  was  a  Hottentot.  Sub- 
clavian tied  same  time.  (See.) 
Autopsy:  Sac  ruptured  just  be- 
low ligature. 

Persistent  hemiplegia  (right) 
after  op.  Patient  died  some 
months  later  ;  cause  not  jjiven. 

Pleuro-pneumonia  (slight)  fol- 
lowed operation. 

"  Paralysis  of  right  (?)  side  fol- 
lowed." (Norri-.)     Dis  a/. 

Died  14  months  later  of  gastric 
trouble. 


Paralysis  after  operation. 

Dyspnoea  followed  op.  ;  muco- 
purulent fluid  in  bronchial! 
tubes  ;  thrombus  in  carotid. 

Slight  cerebral  symjitoms  result- 
ed Subclavian  tied  2  years 
later.    Distal. 


Autopsy  :    Fract.  2d  and  3d  cer- 
vical  vertebrae  ;   abscess  ;    me- 
ningitis,  etc.     Solil    throml)«8- 
on  Loth  sides  of  ligature, 
dbtn  day.    Cerebral  Ball  entered  point  of  nose   rajio^ 
complications.  ]  ed  toward  left  ear.  and  lodged",- 

hem.  left  ear  ;  30  days  altt-r  op- 
eration patient  left  his  bed  :;  on 
37th  day  pain  in  head  ;  died 
next  day.  Autopsy  ;  Pus  at  base 
of  bram,  inflammation  of  me- 
ninges, softeuin,'  of  left  hemi- 
sphere Wound,  of  mcerual 
maxillary. 


50 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
Information. 


Cause  of 
operation. 


<=* 


oil 


Fischer,  1864. 


do. 
do. 


Fisher,  H.  N. 

1862. 
Finley,  1S21. 

f  Foote,  1867, 
Cincinnati. 


L  do. 

Follin. 

Forster,  1852. 

Fouilloi,  1828. 

Fox,  1848. 


Fleming,  1803 
(British  Navy). 


Freye  and 

Botana. 

Fricke,  1826. 

Frothingham, 

G.  E.,  Mich., 

1875. 

Frothingham, 
G.  E.,  Mich., 

1872. 


Gamgee,  S., 

1871. 
Gaunit,  1827. 
Gensoul,  1826. 
Gibb,  G.,  1857. 


Gibhs,  R.  W., 
1872. 

Gibson,  1832. 

Gibson,  C.  B. 

Goodlad. 

Guntner,  1872. 
Giinther. 


Arch.  Klin.  Chir. 
'•'    do. 


Med.  Surg.  Hist.  Eeb. 

Norris  Contrib. 

N.  Y.  Med.  Jr.,  March. 
1869. 


do. 
Arch.  Klin.  Chir. 

do. 

Arch.  Klin.  Chir.; 

Norris  Contrib. 

Am.  Jr.  Med.  Sci., 

Oct.  1S49,  p.  387. 

Norris  Contrib.; 
Arch.  Klin.  Chir. 


Arch.  Klin.  Chir. 

Arch.  Klin.  Chir.; 

Norris  Contrib. 

Am.  Jr.  Med.  Sci., 

Oct.  1876. 


Am.  Jr.  Med.  Sci. 
Jan.  1877. 


Lancet,  June  3, 1871. 

Arch.  Klin  Chir. 

do. 

Lancet,  1857,  vol.  ii. 

p.  495. 

Charles.  Med.  Jr., 

1874;  Am.  Jr.  Med. 

Sci.,  1874. 

Norris  Contrib. 

do. 

Med.  Chir.  Trans.,  vol. 
vii.  p.  112. 

Schmidt  Jahrb.,  B. 

158,  p.  35. 
Arch.  Klin.  Chir. 


Mid  ....  Shot  ■wound. 


Mid 
age. 


17 
35 

Mid 

age. 


do. 

Hem.;  removed 
thyroid  body 
(sup.  thyroid). 

Shot  w'd  inferior 
maxilla. 

Fungus  antri. 

Traum.  pulsating 
tumor  left  orbit. 


do. 

Kemoved  carcino- 
ma of  tonsil. 

Punct.  w'd  mouth 
(fallonumbr'la) 

Removed  tumorof 
pai'otid. 

Aneur.  of  external 
carotid. 


3  days. 


Some 
months. 


Suicidal  cut-thr't 


Aneurism  of  both 
carotids. 
Cancer  of  parotid. 

Traum.   aneurism 
common  carotid. 


Pulsating     tumor 
of  orbit. 


An.  of  com.  caret., 
high  up  (spont.). 

Carotid  aneur. 

Rem.  inf.  max. 

Hem.  (fall  on  dish, 
and  carotid  di- 
vided). 

Shot  wound ;  an- 
eurism of  left 
submax.  region. 

Medul.  tumor  of 
neck. 

Osteo- sarcoma  of 
jaw. 

Immense  tumor  of 
pai'otid. 

Removed  tonsil. 


Stab  of  int.  max, 
artery. 


Short 
while. 


8  days. 


Below 
omo- 
hyoid. 


Below 
omo- 
hyoid. 


Below 
omo  hy 


Few 
hours. 


5  years 

6  years 


6  days. 


At  omo 
hyoid. 


2.5,  26, 
27  Deo. 


Aug.  16 

1S75. 


THE    COMMON    CAIIOTII)    ARTERY. 


51 


Common  Carotid  Arte/nj — continued. 


No. 

Date  of 
operation. 

Hemorrh'ge 
occurred, 
after  op. 

Sdg" 

"9 

RESULT. 

REMARKS. 

Condition. 

Recovery. 

Cause  of  death, 
days  after  op. 

214 

April  IS, 

1S64. 

do. 

June  12, 

18')4. 

Dec.  27, 

1862. 

July  27, 

1824. 

r  Juno  22, 

1867. 

1          [1867. 
L  July  20, 

Once. 
2d  day.' 

2d  day;  hom.;  coma.  Luni;  iiiiurcd  also. 

215 

210 

11 
9 

Recovered. 

Cured. 

Several  days. 
10th  day. 

ConvulsionB  on  tightening  liga- 

•^17 

ture.  Autopsy:  No  thrombus 
at  lig. 

?1S 

Recovered. 
Recovered. 

Recovered. 
Recovered. 

Recovered. 

Recovered. 

Recovered. 

Recovered. 
Recovered. 

Not  cured. 
Cured. 

•^ll 

After  Ist  operation  hruit  ceased, 
liut  returned  in  2  hours.  After 
30  days,  symptoms  being  unfa- 
vorable, the  rii;ht  carotid  was 
secured;  the  bruit  ceased,  but 
again  returned  ;  ultimately 
cured.  Discharged  patient  in 
3  weeks  after  last  operation. 

?,?n 

w,i 

No  symptoms  of  interest  fol- 
lowed. 

Paralysis  of  right  side  for  9 
months. 

fm 

1S52. 
1S28. 

Oc'.21, 

1848. 

Oct.  17, 
1S03. 

Cured. 
Cured. 
Cured. 

Cured. 
Cure  of  one. 

223 

15 

20 

7 

?,1^5 

lowed,  which  gradually  disap- 
peared. 

'^■^fi 

IStli  day.     Cancer. 

ginal  wound.  Abernethy,  Flem- 
ing, and  CoM'eswell  tied  the 
carotid  in  18U3. 

^17 

?I'^S 

Sept.  7, 
lS7o. 

March  29, 
1872. 

1871. 

1827. 

1826. 

AuiT.  30, 

1857. 

1872. 

Nov.  20, 
1832. 

June  12, 
1844. 

Sept.  5, 
ISlo. 

June  27, 
1S72. 

12 

18 

Recovered. 
Recovered. 

Cured. 
Cured. 

Internal  jugular  vein  also  tied  ; 
no  cerebral  symptoms  noted;  2 
ligatures  to  artery  ;  voice  per- 
manently impaired. 

Cerebral  symptoms  for  several 
weeks  ;  pulsation  returned  ; 
growth  of  tumor  retarded  for 
3  years,  then  began  again  ;  ex- 
tirpated with  eye ;  hem.  fol- 
lowed, and  orbit  was  tamponed 
with  liut  in  Monsell's  solution. 

No  cerebral  symptoms  followed. 

?,^9 

^sn 

6th  day.    (Cancer  of 
rectum  ?) 

15th  day. 

231 

Recovered. 

Cured. 

232 

^33 

6th  day, 
slight. 

sup. 

35 

inf.  48 

Recovered. 

Recovered. 

Recovered. 
Recovered. 
Recovered. 

Recovered. 
Recovered. 

Cured. 

Cured. 

Cured. 
Cured. 
Cured. 

Cured. 
Cured. 

Difficult  deglutition  for  several 
days  ;  both  ends  of  artery  tied. 

Paralysis  right  side  after  opera- 
tion, which  was  much  dimin- 
ished after  lapse  of  1  year. 

234 

235 
236 
237 

36 
22 

n 

238 

measured  20  inches  :  removed 
after  ligature  was  applied. 

After  ligature  of  the  common 
trunk  the  hemorrhage  persist- 
ed and  the  iuternal'maxillary 
was  tied,  which  arrested  hem. 
The  ligature  to  the  common 
trunk  was  then  removed.  (It 
is  likely  that  the  tightening  of 
the  ligature  by  dividing  the  in- 
ternal coat  of  the  vessel  oblit- 
erated its  trunk  as  in  ligation.) 

?,39 

52 


PRIZE    ESSAY. 


Surgical  History  of  the 


No. 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


«  I 


o.o 


o  ^- 


240 

241 
242 


243 
244 
245 
246 

247 
248 

249 
250 


251 
252 
253 


255 

2S6 


259 

2eo 


Gunderlach. 
1S31. 

(MoUer), 
L         1832. 
Guthrie. 


Gurlt. 
do. 

Von  Graefe, 

1829. 
Von  Graefe, 

1821. 
Green,  1831. 

Green,  Isaac. 


Greene,  F.  C, 

1863. 
Graudchamp 
(Pinel),  1839. 


Greig,  1S62. 

Griffith. 

Gruening,  E. 
N.  Y.,  1875. 


Hall,  J.  Z.,  1864. 

Halsted,  1857. 
do.       1858. 


Arch.  Klin.  Chir. 


Lancet,  1850,  vol.  ii. 
p    143. 


Arch.  Klin.  Chir. 

do. 

do. 

do. 

Norris  Contrib. 

New  York  Med.  Jr. 
July,  1857. 

Med.  Surg.  Hist.  Keb. 

Arch.  Klin.  Chir 


Edin.  Med.  Jr.,  1862, 

p.  446. 
Med.  Surg.  Hist.  Eeb. 

Archives  Otology  and 
Ophth.,  vol.  V.  No.  1, 
1876 ;  note  to  author. 


Med.  Surg.  Hist.  Eeb, 


New  York  Med.  Jr., 

March,  1869. 

do. 


do.       1839,         New  York  Hosp. 
or  Halstead.      Notes,  vol.  iv.  C.  496. 


Hamilton, 
1838  (of 
Ohio  ?). 


L       do.  18.39. 
Hamilton,  Prof. 
Frank  H.,  1853 


Arch.  Klin.  Chir. 


do. 

Notes  of  cases  from 
Prof.  Hamilton. 


Mid 

age 


Mid 

age 


L. 


Aneur.   anast.  of 

frontal  and  nasal 

regions. 

do. 

Suicidal  cut-thr't 
common  carotid 
at  bifurcation 


Hem.;  shot  w'd. 

Hem.  of  external 
carotid. 
Wound  of  neck. 

Removed     lower 
jaw. 
Aneurism, 

Suicidal  cut-thr't; 

w'd  of  superior 

thyroid. 
Shot  w'd  of  face. 

Pulsating    tumor 
of  face. 


Aneurism  of  orbit 
(fall  on  head). 

Shot  wound  of  su- 
perior maxilla. 

Vascular  proiru- 
sion  of  both  eyes 
(fall). 


SJ  y'rs. 


5f  y'rs. 
8th  day. 


2  years 


14  days 


3  mos. 


Shot  w'd  of  face. 


Aneur.    of    orbit 

traumatic. 
Euceph.  tumor  of 

outer  canthus  of 

left  eye. 

Enceph.  tumor  of 
diploe. 


Epilepsy. 


Sarcom.  antrum  of 
Highmore. 


3j  y'rs. 


From 
child- 
hood. 


do. 
Over  7 
months. 


May  27. 


June  15, 


Above 
omo- 
hyoid. 


Above 
omo- 
hyoid. 


Above 
omo- 
hyoid. 


Aug.  21 


June  16. 


Sept.  4. 


Often 
for  2  or 
3  w'ks. 


THE    COMMON    CAROTID    ARTEKY. 


Common  Garoiid  Artery — continued. 


Date  of 
operation. 


a 


Condition.    Recovery. 


CauHe  of  death, 
day8  after  op. 


KEMARKS. 


Sept.  l.S, 
1831. 


Jan.  18, 
1832. 


Auff.  23, 
18(iB. 
1866. 

1829. 

July  26, 
1S21. 

April  15, 
1831. 


June  16, 
1S63. 
1839. 


March  30 

1SC2. 
July  10, 

1S64. 

June  8, 

1875. 


Sept.  f 
186-1. 

1857. 

1858. 


1839. 
Au?.  '38. 


L  Mar.  '39. 

Dec.  24, 

185!. 


Recovered. 
Recovered. 


Not  cured. 
? 


Next  day. 


Recovered. 


3  weeks. 

3d  day.     Coma. 


Recovered. 
Recovered. 
Recovered. 

Recovered. 
Recovered. 


Cured. 


10th  day. 


Recovered. 


Cured. 


2d  day. 


7th  and 
14th 
days, 

severe. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Cured. 

Cured   (loss 
of  eye). 


Not  cured. 
Improved. 


Cured. 
Cured. 


Patient  died  later  of  variola. 

Ligature  to  cnmmon  trunk  did 
not  arrf'st  hem.;  internal  car- 
otid tied,  and  «till  hcmorrhaco 
roKulted,  uliinh  ceaHKivilh  the 
lipntiirfof  the.  fixlernol  cor'ilirl. 
Internal  jutfiilar  vfin  tied  with 
lateral  lif/aturo.  For  other  cases 
of  Guthrie  see  last  page. 


Autopsy;    Brain  inflamed. 
3d  day,  paralysis  of  right  side. 


'Patient  became  imbecile  and 
died  some  months  later  of  cho- 
lera." 


During  previous  year,  the  two 
facials,  the  transverse  facial, 
infra-orbital,  and  temporal  ar- 
tery of  the  affected  side  were 
tied,  with  no  effect  upon  tuinor. 
No  cerebral  symptoms  followed 
ligature  of  common  trunk. 

'■  Fell  down  stairs." 


"Disease  caused  by  fall.  .Sup- 
posed fracture  at  base  of  cra- 
nium, with  communication  be- 
tween carotid  artery  and  ca- 
vernous sinus." 


"Sight     impaired     in    affected 

eye." 
Tumor  diminished  at   first,  but 

began    to   grow   again,   and  10 

months   later   it   was   removed 

with  the  eye. 
"  Died  several  months  later  from 

disease  and  hemorrhage." 

Although  attributed  to  Prof.  F. 
H.  Hamilton  by  many  writers, 
was  not  performed  by  him.  I 
have  his  authority  for  this  cor- 
rection.— Author. 

Polypus  in  right  antrum  causing 
protrusion  of  eyeball,  depress- 
ing roof  of  mouth,  and  closing 
rightnostril  ;patient  weak  from 
loss  of  blood.  After  operation 
patient  complained  of  slight 
pain  in  right  side  of  head  ;  hem. 
from  wound  on  7th  day3  pints  ; 
arrested  by  pressure  in  wound  ; 
on  14th  day  vomiting  caused 
hem.  from  nose  ;  tumor  staii  m- 
ary  for  some  time  ;  cure  com- 
plete. 


54 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
opevator. 


Source  of 
iaformation. 


Cause  of 
operation. 


"=.2 

O  ;3 


261    Hamilton,  Prof. 
Frank  H.,  1854 


do. 


do. 


do. 


do.        1860. 


do.        1865. 


do.        1866, 


do. 


269 

do. 

1869 

270 

do. 

271 

do. 

1877 

Notes  of  cases  from 
Prof.  Hamilton. 


do. 


M. 


Aneur.  facial  art-  6  w'ks. 
ery  (traum.  false; 
stab  pen-knife) 

Medul.  sarcom.  of  2  years, 
angle     of      right 
jaw    (tumor    re- 
moved). 


Hem.;  polypus  of 
nose  and  antrum. 


Medullary  sarco- 
ma of  right  an- 
trum. 


Erect,  tumor  of 
outer  angle  of 
right  eye. 


5  years. 


Several 
years. 


6  w'ks. 


Hem.    of    ranine|  5  days, 
artery. 


Medul.  sarcoma  of 
superior  maxilla 
(recurrent). 


Removed  left  sup. 

maxilla   for  me- 

dullaiy  sarcoma. 

do. 

do. 


12  y'rs. 


6  mos. 


Below 
omo- 
hyoid. 


Above 
omo- 
hyoid. 


Above 
omo- 
hyoid. 


Above 
omo- 
hyoid, 
do. 

do. 


July  4. 


At  time 
of  in- 
jury. 


Often 

and 

profuse. 


Often. 


July  10. 


Often, 

but 
slight. 


THE    COMMON    CAROTID    ARTERY. 


DO 


Common  Carotid  Artery — continued. 


Date  of 
operation. 


W 


30  o 


Condition. 


Recovery. 


Cause  of  death, 
days  after  op. 


261  ,     Aug.  15, 

'      I8r)4. 

1 

262  Nov.  10, 
ISoo. 


263 


264 


266 


267 


All?.  29, 
lSu7. 


Aug.  1.859. 


Feb.  12, 
1S60. 


An?.  15, 

1865. 


Sept.  5, 
1866. 


None. 
After. 


do. 


Recovered. 


None. 


Next 

day, 

slight. 


271 


May  12, 
1869. 


Feb.  25, 

1877. 


10 


Recovered. 


Recovered. 


Recovered. 


-28 


None. 


Had 

not 
come 
away 
3  mu's 
after 
oper, 


Cured. 


(Temporary 

improve-^ 

ment.) 


No  benefit. 


Not  cured. 


Recovered. 

Recovered. 
Recovered. 

Recovered. 


10    hours.       Shock, 
hem.,  aniesthetic. 


39th  day.  Ilemor'ge, 
exhaustion. 


16th  day.    Anaemia ; 
exhaustion. 


Not  cured. 


Not  cured. 


No  cerebral  symptoms  noted ; 
pulsation  in  tumor  ceased  im- 
mediately. 

Tumor  ^rnw  very  slowly  until 
last  2  inonthH  ;  size  of  coeoanut ; 
over  a  lartje  portion  of  face  and 
neck  ;  was  excised  ;  hem.  to  2or 
3  pts.  ;  several  ligatures  in  w'd  ; 
no  symp's  of  cerebral  disturb'e. 

Br.  Axtreo  liad  attempted  to  re- 
move tumor,  but  had  to  desist 
on  account  of  hemorrhage  ;  ex- 
treme suffering  ;  no  symptoms 
of  cerebral  disturbance. 

7  y'rs  previously  dentist  broke  a 
tooth  on  right  side,  followed  by 
intense  pain  ;  3  years  before  op. 
hem.  1  y'r  before  eyeball  began 
to  protrude;  after  op.  eye  aud  tu- 
mor removed  ;  hem.  profuse  but 
easily  controlled.  Disease  ret'd 
some  time  later  and  proved  fat'l. 

Tumor  covered  right  temple,  had 
pushed  eye  out  and  destroyed 
it;  soft,  elastic,  with  distinct 
bruit;  tumor  returned  later  and 
patient  died  from  it. 

On  July  4th,  patient  had  lower 
jaw  broken  on  both  sides;  ab- 
scess formed  and  the  attending 
surgeon  (not  Dr.  H.)  accident- 
ally divided  the  ranine  artery, 
in  open'g  the  abscess. — Author. 

"  3  months  previously  tumor  had 
been  removed  by  Prof.  Lewis  A. 
Sayre,  but  returned  in  a  very 
malignant  form.  Day  after  lig- 
ature of  carotid,  paralysis  ou 
left  side  of  face  and  right  side 
of  body ;  comatose  and  slight 
hem.  from  roof  of  mouth  ;  pa- 
tient died  2  mos.  later.  Autopsy: 
Granular  dei;eneration  of  kid- 
neys and  cancerous  deposit  in 
various  organs."  (The  coma 
and  paralysis  were  doubtless 
due  to  ligature  of  the  ^carotid. 
Death  iu  great  measure  due  to 
disease. — Author.) 

Patient  died  6  months  later  of 
disease. 

Patient  died  several  mos.  later 
of  disease. 

"  Patient  of  hemorrhagic  diathe- 
sis. Sharp  pain  down  neck  to 
collar  bone  some  b"rs  after  op." 

Submaxillary  gland  removed; 
"^vouud  healed  nicely  ;  3  months 
later  disease  seemed  on  the 
point  of  returning  ;  patient  lost 
siyht  of  after  this.  Prof.  Ham- 
ilton has  furnished  me  notes  of 
one  other  case  which  occurred 
on  McCIellau's  retreat  after  the 
"Seven  Days'  Battle."  The 
common  carotid  was  tied  to  ar- 
rest hem.  from  guushot  wound 
of  the  ext.  carotid;  the  hem. 
ceased,  but  the  case  was  lost 
sight  of  in  the  confusion  of  the 
retreat.  In  every  instance  he 
has  used  his  own  "aneurism 
needle."  which  is  described  in 
his  work  upon  the  -'Priu.  and 
Prac.  of  Surgery." — Author. 


56 


PRIZE    ESSAY. 


Surgical  History  of  the 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 
.2  2 

"S  'i 
Q 

o  .2 

'a  "=^ 
.|  to 

.25 
fi.a 

t«  to 

6 

bo 

2 

9.1'?. 

Hargrave,  1849. 
Hart,  1861. 

Heath,  Christo- 
pher, 1865. 

do.  1872. 
Heine,  1869. 

do.     1871. 

do.     1873. 

Hebenstreit. 

Hendricks, 
1864. 

Herpin,  1844. 

Hewson,  1850. 
do.      1867. 

Von  Hippel, 

1873  ? 
Hobart,  1857. 

Hoda;son,  ZSoO. 

Holscher,  1819. 

Holmes,  T.,1S75 

(London). 

do.    1S7U-2? 

Holmes,  E.  L. 
(Chicago). 

Holt,  1860. 

Arch.  Klin.  Chir. 

Lancet,  1862,  vol.  i.  p. 
271. 

Lancet,  Jan.  1867. 

Brit.  Med.  Jr.,  Feb. 

1877. 

Long-w'orth,  Prize 

Thesis. 

Wien.  Mediz.  Woch., 
1874,  p.  661. 

Wien.  Mediz.  Woch., 
1874,  p.  679. 

Arch.  Klin.  Chir. 

Med.  Surg.  Hist.  Reb. 

Arch.  Klin.  Chir. 

do. 

Am.  Jr.  Med.  Sci., 

July,  1876,  p.  20;  Dr. 

Thos.  G.  Morton. 

Schmidt  Jahrb.,  B. 

163,  S.  59. 

Med.  Times  &  Gaz., 

1830,  vol.  i.  p.  64. 

Arch.  Klin.  Chir. 

Norris  Contrib. 

Am.  Jr.  Med.  Sci., 

April,  1877. 

Lancet,  1872. 

Schmidt  Jahrb.,  B. 
172,  p.  70. 

Lancet,  1861,  vol.  i.  p. 
560. 

M. 
M. 

F. 

M. 
M. 

M. 

M. 

M. 

M. 

F. 

M. 
M. 

M. 
M. 

F. 
M. 
F. 

M. 
M. 

M. 

61 

11 

30 

21 
32 

50 

L. 
L. 

K. 

L. 
E. 

E. 

Hem.;      puncture 
wound. 

Aueur.    anast.    of 
upper  lid  and  or- 
bit. 

Supposed    aneur. 
of  innominate. 

Aortic  aneurism. 

Hem'ge  ;  removed 
cirsoid        aneur. 
of  ear  and  scalp. 

Removed  sarcoma 
of    right     tonsil 
(prepart). 

Recurrent    sarco- 
ma of  neck. 

Eemoved  tumor  of 
parotid     (wound 
of  facial). 

Shot   w'd   of  face 
and  neck. 



^73 

?,74 

4  mos. 

Above 
omo- 
hyoid. 

^ys 

^7fi 

5  days. 

Several 
years. 

277 

Above 
omo- 
hyoid. 

Below 
omo- 
hyoid. 

27S 

279 

280 

25 

59 

48 
51 

21 

L. 

L. 

E. 

E. 
L. 

Above 
omo- 
hyoid. 

2S1 

282 

Aneur.  of  external 
carotid. 

Aneur.  of  innomi- 
nate. 

Traumatic  pulsat- 
ing tumor  orbit. 

Traumatic    aneu- 
rism of  carotid. 

do. 

Aneurism. 
Aortic  aneurism. 

Innominate  aneu- 
rism. 

Intra-cranial    an- 
eurism (of  pitui- 
tary body). 

Aneurism  of  caro- 
tid (low  down). 

283 

Some 
time. 

10  w'ks. 

284 

■285 

6  mos. 

•286 

287 

23 
21 

50 
21 

30 

K. 
L. 

E. 
L. 

R. 

■288 
289 

"290 

Some 
time. 

2  mos. 

291 

Below 
omo- 
hyoid. 

THE    COMMON    CAROTID    ARTKRY. 


57 


Common  Carotid  Artery — continued. 


Date  of 
operation. 


!-.    tj    >- 
O   P   (P 


a  o  o 


"t^S. 


Kecovery. 


Condition. 


Cause  of  death, 
date  after  op. 


KKMARK.S. 


Jan.  2.j, 

1840. 
1861  1 


1865. 


Feb.  1872. 

is;9. 


Dec.  IS, 
1864. 

July  26, 
1844. 

June  19, 

1850. 
1867. 


Sept.  3, 
1857. 


18.50. 

Sept.  27,'19, 

Oct.  21, 

1875. 


141  h 
day. 


Nov.  20, 
1860. 


After. 


28,29 


2  or  3 
times. 


After. 
do. 


18 


After    14th    day,  of 
bronchial  catarrh 


Recovered. 


Recovered. 


Cured. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Recovered, 
Recovered. 
Recovered. 


ISth 
day. 


Improved. 
Cured. 


Improved. 


Improved. 
Cured. 


Cured. 

Cured. 

? 


Cured  (?) 


10th  day. 


90th  day.     Hem. 


No  «yrnptomH  of  cerebral  disturb- 


'  Subclavian  in  .Id  div.  tied  Harne 
time  ;  tumor  reduced  in  Kize 
and  patierit  much  improved, 
thouijh  of  di»Holute  habitB." 
niKtil.  (In  Lanrot,  July  2, 
1870,  is  notice  of  death  of  this 
patient  on  Dec.  8,  1869,  from 
I'uptnre  of  aortic  anenrism. 
The  intiominate  was  not  in- 
volved in  tlie  disease. — Author.) 

Died  4  years  later  from  rupture 
of  sac.     Distal. 

'  Ext.  carotid  tied  when  tumor 
was  removed;  5  days  later 
hem.  and  lif;.  common  carotid." 
(See  Surgical  History  oi'  the 
Ext.  Carotid  Artery.— yl7///(or.) 

Not  a  particle  of  hemorrhage! 
"  Operiite  man  so  trucken  wie 
an  der  Leiche."  6th  day  pa- 
ralysis left  sidn  and  delirium  ; 
osteo-plastic  resection  of  lower 
jaw  durinsr operation.  Autopsy: 
Thrombus  above  and  below  lig- 
ature, continuous  clot  from, 
enroti'^  into  ri'.ht  siihclnvi"n 
'  14  ligatures  in  wound  of  extir- 
pation." 


Hera,  resulted  from  ulceration 
of  wall  of  internal  j  ugular  vein. 

10  months  later  pulsation  was 
noticed  in  opposite  eye  ;  arrest- 
ed by  cold  application. 


12th    day.     (Serous 
effusion  in  lungs.) 


57th    day. 
rhage. 


Distal. 

No  symptoms  of  cerebral  disturb- 
ance  noted. 

Afi  er  operation  tumor  increased, 
was  opened,  and  to  arrest  hem. 
a  small  artery  was  tied.  Oct.  9, 
another  hem.,  and  a  second  liga- 
ture was  applied  (to  carotid), 
which  came  away  on  Nov.  4. 
Hodges.  Hobart,  2d  case.  See 
appendix. 


Patient  was  alive  after  13  months 
had  elapsed 

Right  subclavian  tied  same  time 
and  tumor  treated  by  gnlvnno- 
puncturK  ;  carb'd  catgut  used  ; 
sac  sloughed  causing  death. 

Died  3^  years  later  of  disease. 
Autopsy  :  Tumor  of  pituitary 
body  large  as  hen's  egg,  pressed 
upon  carotid,  causing  aneuris- 
mal  dilatation  of  this  vessel  and 
atrophy  of  both  optic  nerves. 

"After  operation  pain  in  head 
and  retention  of  urine.  (Feb. 
4,  much  better  and  sent  to  Mar- 
gate?)" 


58 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


Caiise  of 
operation. 


0.2 


M3 


292       Horner,  1S32. 

Hueter,  1864. 

Hunt,  1862 
(Fortress  Mon- 
roe) . 
Hunt,  Wm., 
1868. 

Hunter,  1843. 

do. 

Hutchinson, 
1856. 

Hutchison, 
Prof.  J.  C. 
(Brooklyn). 

do.  1866. 


do.  1877. 


Hutton,  1842. 


Isaacs,  C.  E., 
18.i5. 


Jaeger,  1836. 

Jameson,  1820. 

Jobert,  1836. 

do.     1839. 
Johnson,  C.  H., 

1850. 

Johnson,  1842. 
Jiingken. 


Norris  Contrib. 

Arch.  Klin.  Chir. 

Letter  to  author  from 
Prof.  Alfred  C.  Post. 

Am.  Jr.  Med.  Sci., 

July,  1876;  Dr.  T.  G. 

Morton. 

Arch.  Klin.  Chir. 

do. 

Med.  Times  &  Gaz., 
March,  1856,  vol.  i.  p. 

209. 

Letter  to  author  from 

Prof.  H.;  Am.  Med. 

Times,  April,  1861,  p. 

20. 

Letter  to  author ; 

N.  Y.  Med.  Record, 

Aug.  1867. 


Operation  witnessed 

by  author  ;  notes  from 

Urs.  H.  W.  Kand  and 

J.  E.  Richardson. 


M.     34 


Arch.  Klin.  Chir. 


N.  Y.  Med   Jr.,  July, 

1857. 


Arch.  Klin.  Chir. 

Norris  Contrib.  cit. 

Arch.  Klin.  Chir. 

Norris  Contrib. 

Lancet,  1S50,  vol.  ii. 

p.  118. 

Norris  Contrib. 

Arch.  Klin.  Chir., 
1868. 


58 

Mid 
ige. 

28 

60 
29 
60 


Wound  of  throat. 

Hem.,  secondary. 

Shot  w'd  of  neck 
(high  up). 

do. 

Aneur.  in  mouth. 

Aneurism  of  com- 
mon carotid. 

Hem.  ;  cancer  of 
left  submaxil'ry 
gland. 

Puncture  wound 
by  iron  rod  (w'd 
of  internal  max- 
illary). 

Aneurism  of  in- 
nominate. 


Neuralgia  of  3d 
division  of  trifa- 
cial nerve. 


"Not 
long." 


Pew 
hours. 


13  days. 


7  years 


R. 


Innominate  an- 
eurism. 


Hem.;  shot  w'd 
of  angle  of  jaw  ; 
suicide  (single 
ball;. 

Hemorrhage  after 
surgical  opera- 
tion. 

Fungous  tumor  of 
antrum. 

Erect,  tumor  in 
temporal  region. 

Anenr.  of  orbit. 

Hem.  of  pharynx ; 
umbrella  driven 
through  fauces. 

Aneurism. 

Hem,;   aneur. 
anastomosis. 


1  year. 


Below 
omo- 
hyoid. 


Below 
omo- 
hyoid, 
1  inch 
above 
innomi- 
nate. 


13  mos, 
4  mos. 
3  years, 


Sept.  11. 


11  and 
24. 


THE    COMMON    CAROTID    ARTERY, 


59 


Common  Carotid  Artery — continued. 


Date  of 
opiiratiou. 


Juno  18, 
1832. 

Doc.  23, 
18C4. 
1362. 


Aug.  3, 
1843. 


Sept.  2i, 
1860. 


Jan.  16, 

1866. 


June  30, 
1877. 


June  27, 
1842. 


1855. 


May,  1S36. 


Nov.  11, 
1820. 

Ausf.  22, 
1836. 


Hemorrh'ge 
occurred, 
after  op. 

13 

Recovery. 


Condition. 


CauHO  of  death, 
date  after  op. 


KEMARKS. 


May  12, 
1850. 


Jan,  22, 

1842. 


22d 
day. 


None. 


28 


Recovered. 
Rocovorod. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Cured. 
Cured. 


Cured. 


Cured. 


Next  day.     Shock  ; 
oxliaustiou. 


4th  day. 
10th  day. 


Cured. 


Cured. 


Cured. 


Cured. 
Cured. 


Cured. 
Not  cured. 


41st  day.  Asphyxia, 


reth  day. 


16th  day.    Hem. 


2d  day. 


"  Slight  cerehral  diHturbanco. 
Internal  carotid  tied  also. 


3  days  hefore  death  symptoms  of 
paralysis  on  right  side. 

"  14  hours  afteroperation  patient 
seized  with  epileptic  convul- 
sions, which  ceased  later." 

Subclavian  was  not  tied  owing 
to  its  displacement  and  obliter- 
ation by  tumor.  Autupsy  :  An- 
eurism of  aich  of  aorta  and  in- 
nominate. Both  enrnlidn,  right 
vert  Aral  and  suhct  avion  artery 
occlutie.d,  and  nn  symptnma  of 
cerehral  a^immial     Distal. 

Upon  two  previous  occasions, 
several  teeth  had  been  extract- 
ed, the  alveolar  processes  re- 
moved, and  once  the  dental 
branch  of  ?A  division  of  ;'jth 
nerve  had  been  exsected  but 
without  result.  Carbolized  cat- 
gut and  antiseptic  dressings 
used.  Dr.  Jno.  D.  Rushmore 
writes  me,  Aug.  18,1877,  ''the 
operation  was  followed  by  com- 
plete cessation  of  pain  ;  wound 
healed  by  first  intention  ;  pa- 
tient discharged  cured." 

Tumor  diminished  almost  en- 
tirely  after  operation  ;  epileptic 
convulsions  before  death.  Au- 
topsy :  Risfht  subclavian  also 
occluded  although  not  included 
in  ligature.     Distal. 


No  cerebral  symptoms. 

No  cerebral  symptoms. 
Cure  complete  27  days  after  op- 
eration. 


In  Laneenbeclv's  Archives.  Dr. 
Pilz  gives  a  3d  case  by  Jiing- 
keu,  but  as  the  S''x.  side,  civse, 
and  result  of  the  two  opera- 
tions are  identical.  I  suspect 
this  industrious  compiler  has 
accidentally  repeated  this  case. 
It  is  my  purpose  to  admit  no- 
thiug  in  this  history  that  is  not 
clear  and  positive. — Author. 


60 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  9f 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

O 

d  6 

ft 

o  o 

a  "S 

"ox 

^:2 

6 
t^  ho 

6 

60 

< 

T3 

.d 

■^^^ 

.liingken. 
Karatscharoff. 

Keen,  W.  W., 
1S63. 

Kerr,  1S40. 

Key,  Aston, 
■]830. 

Key  (?),  1S24. 

Key  &  Grouse, 

1811. 

Koch,  1866. 

-    Kuhl,  1S43. 

do. 

do.     1836. 

Kluyskens, 

1840. 

Knagges,  1863. 

Knapp,  H.,  18.58 
(Heidelberg). 

Knowles,  1867. 

Arch.  Klin.  Chir., 

1S6S. 

Med.  Zeit.  Russ.  1846, 

S.  39  :   Arch.  Klin. 

Chir.  cit. 

Med.  Surg.  Hist.  Reb.: 

Otis;  Am.  Jr.  Med.  ' 

Sci.,  1864. 

Edin.  Med.  Journ., 

1844,  vol.  i.  p.  119. 

Lond.  Med.Gaz.,  1830, 

vol.  vi.  p.  702. 

Korris  Contrib. 

Schmidt  Jahrb.,  B.41, 
■       S.  75. 
do. 

Ehrmann,  No.  13 ; 

Norris  Contrib.; 

Arch.  Klin.  Chir. 

do. 

Arch.  Klin.  Chir., 
1868. 

do. 

Lond.  Med.  Times  & 
Gaz.,  1863,  vol.  ii.  p.  8. 

Letter  to  author  from 
Prof.  Knapp. 

Lancet,  June,  1869. 
Arch.  Klin.  Chir. 

Gunther,  199;  Arch. 

Klin.  Chir..  1868. 
Norris  Contrib.,  1868. 

Ehrmann  des  eifets, 
p.  41. 

Arch.  Klin.  Chir., 
1868. 
do. 

do. 

do. 

Lancet,  18.52,  vol.  ii. 
p.  57. 

M. 
M. 

M. 

F. 
F. 

M. 
F. 
M. 

M. 

M. 

F. 

M. 

M. 

M. 

M. 

F. 
F. 

M. 

M. 
M. 

M. 

M. 

M. 

33 

33 

67 
61 

40 
53 
38 

53 

53 

43 

23 
15 

9 
mos 

40 
48 

49 

29 

48 
36 

58 

65 

30 

L. 
R. 

L. 

R. 
R. 

R. 
R. 

L. 

R. 

R. 

L. 
R. 

L. 

R. 
L. 

R. 
R. 

R. 

R. 

R. 
L. 

L. 

Stab  wound  of  ex- 
ternal carotid. 

Short 
while. 

'^^'>, 

313 

Shot  wound    of 
superior  max. 

Vascular    tumor; 
supposed  aneur. 

Aneurism  of  in- 
nominate. 

' 
Aneurism. 

Aneurism  of  caro- 
tid. 
Hem.;  shot  w'd. 

Aneurism    anast. 
oecip.  traum. 

do. 

Vascular  tumor 
of  frontal  region. 

Aneurism,  traum. 

Aneurism  of  caro- 
tid, traum. 

Intra-cranial  turn. 

Aneurism  of  caro- 
tid (low  down). 

Headache. 

Removed   tumor 
of  neck. 

Aneurism  of  caro- 
tid (at  root). 

Above 
omo- 
hyoid. 

Julyl. 

July  8. 

ii.i 

=!lfi 

5  mos. 

^17 

?1S 

^19 

24  y'rs. 

520 

do. 
4  mos. 

3  mos. 

4  mos. 

?21 

?22 

323 

Below 
omo- 
hyoid. 
Above 
omo- 
hyoid. 

324 

325 

3W 

3?7 

Labat. 
Lambert,  1S27. 

Von  Langen- 
beck,  182.5. 

do. 

do.    1845. 

do.    18.J9. 

do. 

Lane,  1852. 

3?8 

329 

330 

perior   thyroid 
artery. 
Hem.  carcinoma. 

Traumatic  aneur- 
ism of  carotid  ; 
shot  wound. 

Removed  epithe- 
lial  cancer  of 
neck. 

do. 

Aneurism  of  caro- 
tid (low  down). 

5  days. 
14  days. 

3S1 

339, 

2  years. 

333 

334 

5  w'ks. 

Above 
omo- 
hyoid. 

THE    COMMON    CAROTID    APwTEKY. 


61 


Common  Carotid  Arlery — continued. 


Dato  of 
operation. 


!■ 

«      ■   Ph 

ia  S  c. 

5>^  • 

o  s  S 

"  b« 

a  ge 

Kecovery. 


Condition. 


Cause  of  death, 
date  after  op. 


REMARKS. 


July  16, 
lSJ:i. 

April  :iO, 
1810. 

July  20, 
1S30. 


Jan.  24, 
1824. 

Sept.  9 
1S41. 

July  22, 
186(3. 

r  May  24, 
I        1S43. 

j     Au!.'.  4, 
1       1834. 


Sept.  16, 
1836. 


Aug.  .5, 
1840. 

Jan.  16, 
1863. 

1858. 


3,4, 
slight. 

Several 
times. 

3d  day. 


Eecovered 
Kooovered 


Cured. 
Cured. 


4th    (lay.     Corehral 
complications. 


Rocoverod. 


4  hours.     Coma. 


10th  day. 


Recovered. 
Recovered. 

Recovered. 

Recovered. 


Cured. 
Cured. 

Not  ciired. 

Cured. 


2d  day. 


22       Recovered, 
34 


March  1, 
1827. 


? 
1845. 


Jan.  13, 
18o9. 

May  30, 
1859. 


July  7, 
18j2. 


11,49, 
61st 
day. 


No  better. 


14 


Recovered. 


Eecovered 


Recovered. 
Recovered. 


Improved. 


(?) 
Cured. 


44th  day. 

Next  day.    Disease. 

35th  day.     Coma. 


Sujipuration  in  sac  whicli  had  to 
be  opened. 

Paralysis  .35  days  after  opera- 
tion. Autopsy:  Abscess  in 
brjiin. 

Patient  died  0  months  after  op- 
eration from  pneumonia. 

Autopsy  :  Mouth  of  hft  carotid 
was  about  one-tonth  size  of  rest 
of  vessel  ;  both  vertebrals 
small.    Distal. 


No  had  symptoms. 

Ball  entered  at  infra-orbital  for- 
amen, s]iin.  process,  2d  and  3d 
cervical  vertebrje. 

One  year  after  a  fall  from  a  horse 
on  occiput ;  disease  began  72 
days  after  1st  operation. 

The  2d  carotid  tied  ;  no  mark- 
ed cerebral  symptoms  follow- 
ed the  2d  operation,  although 
convulsions  occurred  after  the 
1st. 

Cerebral  symptoms  followed  ; 
unconscious  4  hours.  Autopsy  : 
Tuberculosis  of  lungs ;  pneu- 
mogastric  nerve  injured  by 
inflammation  of  surrounding 
structures ;  right  .luhclnvion 
■includtd  in  ligature  hy  mistake. 

Died  4  years;  rupture  of  sac ; 
supposed  aneur.  of  vertebral. 

Sterno-mastoideus  divided  in  op- 
eration ;  was  well  united.  Au- 
topsy: Suppuration  of  sac. 

Autopsy:  Vascular  tumor  in 
convexity  left  hemisphere, 
large  as  a  man's  fist,  pressing 
brain  to  right;  parietal  bone 
outward. 

No  cerebral  symptoms  until  34th 
day,  when  paralysis  of  left  side 
complete. 

Died  J 3  months  from  rupture  of 
aortic  aneur.  Autopsy  showed 
above  and  also  varicose  condi- 
tion of  left  choroid  plexus. 


62d  day.    Hem.  ;  ex-;  (Distal.) 
haustiou. 


34  hours.     Coma. 


Autopsy:  Left  hemisphere  con- 
gested ;  right  ausemic  and  se- 
rous effusion. 


12th  day.     (?)  No  cerebral  symptoms.  Autopsy: 

No    brain  lesion.     (Note. — Int. 
jugular  vein  also  tied.) 
Id  day.  Lost  consciousness  before  death. 

Autopsy:  No  brain  lesions.  (In 
this  case  also  the  int.  jugular 
vein  was  tied.) 
6Sth    day.      Inflam-'' Progressed  favorably  up  to  6th 
mation  lung.  i  day.'    Distal;  Bras'dor. 


62 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
inforiuation. 


Cause  of 
operation. 


Lane,  L.  C, 
1873. 


Lane,  Jas.,  1871 
do. 


do. 


Larrey,  1828. 


Lavocherie. 
Laub,  H.,  1874. 

Lauda,  1838. 


Lawrence,  1867, 
England. 

Lawrence,  M. 

Lee,  H,,  1864. 


Legouest. 

Lenoir,  1851. 

Lerylier,  1846. 

Lewis,  J.  B  , 

U.  S.  A.,  1884, 

do. 

Lick  and  Hop- 
mann. 

Lisfranc,  1827. 
Listen,  1841. 


California  State  See. 

Trans.;  Am.  Jr.  Med. 

Sci.,  Oct.  1874. 


Lancet,  Jan.  13,  1872. 
do.      Oct.  14, 1871. 


Wien.  Mediz.  Woch., 
1875,  p.  630. 


Clinique  Cliir.,vol.  ii. 
p.  130. 


Arch.  Klin.  Chir., 

1868. 

Schmidt  Jahrb.,  B. 

167,  S.  266. 

Schmidt  Jahrb.,  B.  30, 
S.  371. 


Arch.  Klin.  Chir. 

(cit.). 

Schmidt  Jahrb.,  No. 

139,  p.  221;  N.  Y.  Med. 

Jr.,  March,  1869. 

Arch.  Klin.  Chir., 

1868. 

Lancet,  Nov.  1864,  p. 

523. 

Lancet,  January  and 
March,  1839. 


Arch.  Klin.  Chir., 

1868. 
do. 

Ehrmann  des  effets, 

p.  48;  Pilz  (cit.). 

Med.  Surg.  Hist.  Reb. 

Otis. 

do. 

Berlin  Klin.  Wochen., 
Aug.  1871,  p.  419. 


Arch.  Klin.  Chir., 
1868;  Norris  (cit.). 


Norris  Contrib. 


Sol- 
dier 


Mid 
age 
Mid 
age 


Neuralgia  follow- 
ing removal  of 
parotid. 


Aneurism  of  caro- 
tid, root  of  neclj. 


Traumatic  aneu- 
rism of  occipital 
artery   behind 
ear. 

Hem.;   stab   w'd 
with    sabre   in 
duel,   right   side 
of  neck,  high  up. 


Hem.  of  carotid. 

Hem.  ;    removed 
part  of  submax- 
illary gland. 

Traumatic    aneu- 
rism of  carotid ; 
stab  wound  of 
neck. 

Hem.;  aneurism, 
traumatic. 

Traumatic  aneu- 
rism of  orbit. 

Hemorrhage. 

Hem.;  opening  ul- 
cerating tumor  of 
neck. 

Traumatic  aneu^ 
rism  of  carotid 
low  down. 


Traumatic    orbit, 
aneurism. 

Erect,  tumor  of 
temporal  region. 

Aneurism  of  caro- 
tid. 

Shot  wound  of  left 
side  of  face, 
do. 

Shot  w'd  of  face. 


Fungus  hrematod. 
(supposed  aneu- 
rism). 

Hem.;  puncture 
of  supposed   ab- 
scess. 


8  days. 


1  day. 


Below 
omo- 
hyoid. 

Above 
omo- 
hyoid. 


July  24, 
do. 


Aug. 
do. 


Near 
innom. 


THE    COMMON    CAROTID    ARTERY. 


63 


Common  Carotid  Artery — continued. 


No. 


Date  of 
operation. 


t<  S  ° 


Recovery. 


Condition. 


Cause  of  death, 
date  after  op. 


335 

336 
337 

338 


340 
341 


343 
344 

345 
346 

347 


1S73? 


Sept.  20, 
1871. 


June  28, 
1871. 


348 
349 
360 
351 
352 
353 


355 


1874. 
1838. 


120tli 
day. 


21 


Recovered. 

Recovered. 
Recovered. 

Recovered. 
Recovered. 


1846. 

Aug.  10, 

18(34. 
Aug.  14, 

lb64. 


4  days. 


Oct.  21, 
1841. 


2  days. 


After. 


14  days- 


Recovered. 
Recovered, 


Recovered, 
Recovered 


Cured. 

Not  curod. 
Cured. 

Cured. 


Treatment  faillntf,  it  wan  acci- 
dentally dlHCovered  tliat  preg- 
Kure  uiKiii  the  carotid  gave  re- 
lief. After  ligature  of  the  car- 
otid it  was  cured. 

Tumor  at  flrHt  diminiHhed,  after- 
ward mucli  enlarged;  Kuhcla- 
vian  tied  Hanie  time.     Distal. 

No  cerebral  .symptoms  ;  temp.  1° 
higher  iu  auditory  meatus  of 
right  (lig.)  side  than  opposite. 

Pulsation  ceased  after  op.  ;  re- 
turned 3  days  ;  cure  in  9  mos. 


Hem.  profuse  before  operation, 
and  was  arrested  by  ligature  ; 
Larrey  supposed  tiiis  a  case  of 
both  external  and  internal  car- 
otids arising  by  separate  trunlts 
from  innominate. — Author. 


Cured. 
Cured. 


Cured. 
Cured. 


Cured. 


Died. 


3d  day. 
2d  day. 


15th  day  (about). 
Cerebral  complica- 
tions. 


After  operation  blind   and  deaf 
on  left  side. 


Recovered 

(?) 


Recovered, 


Not  cured. 


Cured. 


Uied. 

llth-12th  day.  Coma. 


9th  day.  1st,  5th,  2d 


Autopsy:  Wounded  vessel  not 
found  ;  brain  normal. 

Above  ligature  adherent  throm- 
bus. 

Paralysis  of  riglit  side  face  im- 
mediately afteroperation  ;  tem- 
perature right  side  2^  higher, 
sweating  profusely  on  1/ft  s\A&. 
Dr.  Jno.  W.  Ogle  says,  "  want 
of  equilibrium  in  muscles  of 
face,  result  not  of  paralysis  of 
the  light  side,  but  spasm  of  the 
muscles  of  the  left,"  and  "  that 
the  symjiathetic  nerve  was  in- 
jured by  ulceration." 

External  carotid  tied  at  same 
time.     No  hemorrhage  noted. 


Wth  day  paralysis  of  left  side. 

Ball  entered  left  malar  hone,  out 
beneath  left  mastoid  process. 


18th    day. 
disease. 


15th  day.     Hem 


2  mos.  after  operation  aneurism 
developed  at  seat  of  ligature 
(diffuse), cured  by  compress  af- 
ter 6  weeks'  trial. 
Hem.  ;'Fungiis  of  left  cerebral  fossa; 
petrous  portion  tempural  bone 
carious;  internal  jugular  vein 
obliterated. 

A  tumor  in  neck,  thought  to  be 
abscess,  was  opened;  hem.  fol- 
lowed. Autopsy :  Proximal  end 
of  artery  open ;  no  attempt  at 
thrombus. 


64 


PRIZE    ESSAY. 


Surgical  History  of  the 


No. 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


%-. 

o 

o  o 

O   ^ 

.^^      ^ 

■-5  3 

a  d 

-S  3 

•3.2P 

3 

ft. a 

o 

13 

Listen,  1841. 
do.      1S17. 


Lizars,  J.,  1827. 


f    Longmore, 
I  18S3 


Love,  W.  S., 
1861,  U.  S.  A. 


do. 
Liicke,  1865. 


do.      1866. 
Luke,  1829. 


Lancet,  1844,  vol.  ii. 

p.  276. 

Ed.  Med.  Surg.  Jr., 

1820,  p.  72. 


Poland  in  Guy's  Hosp 
Report,  vol.  xv.  1870. 


Lancet,  April  10,  1830, 


Lancet,  .January,  1864 
p.  90. 


Med.  Surg.  Hist.  Eeb.; 
Otis. 

do 

Gaz.  Hebdom  ,  March 

29,  1837;  Arch.  Kiln. 

Chir.,  1838. 

Schmidt  Jahvb.,  B. 
141,  p.  202. 

Norris  Contrib. 


do.     1848.        Lancet,  18^0,  vol.  ii. 
p.  109. 


Luzenherg, 

1S34. 

Lyford,  1818. 

Lynn. 

Macaulay,  1812 
(Calcutta). 


Macgill,  1823, 
Maryland. 


Maclarhlan, 
1825. 


Mac  Manus. 


Mageadie,  1827. 


Mahon,  A 
1838-9 
Mahon,  M, 
1864. 


D., 


Malgaigne, 
1845. 


Norris  Contrib. 

Norris  Contrib.; 

Arch.  Klin.  Chir. 

Arch.  Klin.  Chir., 

1868. 

Norris  Contrib.; 

Ehrmann  des  effets  ; 

Arch.  Klin.  Chir.  (cit) 

do. 
do. 


Norris  Contrib.; 
Arch.  Klin.  Chir. 

Arch.  Klin.  Chir., 
1838. 

NoiTis  Contrib.; 

Arch.  Klin.  Chir., 

18S8. 

Schmidt  Jahrb.,  No. 

1.50,  p.  307. 
Am.  Jr.,  vol.  xlviii. 
p.  276,  1864,  Dr.  Made- 
lung  ;  Arch.  Klin. 
Chir.,  vol.  xvii.  p.  626. 


Arch.  Klin.  Chir., 

1868. 


Mid 
age. 
25 


45 


Mid 
,ge 
23 


Vascular    tumor 

of  neck. 
"  Beating  pain  on 

left  side  of  head 

and  face." 

Subclavian  aneu- 
rism. 


Prep,  resection  of 
superior   max.  ; 
medullary  sarco 
ma. 

Shot  w'd  through 
lai'ynx  ;  epiglot- 
tis carried  away. 

Hem'ge  from  lin 
gual  artery. 

Shot  w'd  of  inf. 
maxilla. 


6  mos. 


L. 


Shot  w'd  of  left 
side  of  face. 

Traumatic  aneu 
rism  of  vertebral 
(supposed  caro- 
tid). 

Spontaneous  pul 
sating  tumor  of 
forehead. 

Hem.;  ulcer thr't. 


Suicidal    wound 
(knife). 


Parotid  tumor. 

Aneurism  of  caro- 
tid, common. 

Second,  hem.  re- 
mov.  carotid. 

Aneurism  of  int. 
maxill.,  tranm. 


Pulsating  vascu- 
lar tumor  of  both 
orbits. 

do. 


Vascular  tumor  of 
scalp,  following 
arteriotomy. 

Cervical  tumor  ; 
carcinoma ;  sup- 
posed aneurism. 

Tumor  of  antrum 
high. 

Stab  of  carotid  at 

bifurcation. 
Hem.;  shot  w'd  of 

lower  jaw. 


7  years. 

4  days. 

Short 
time. 

20  y'rs 
3  w'ks 


Above 
omo- 
hyoid. 


Above 
omo- 
hyoid. 


May  3, 
1863. 


Aug.  13. 
Sept.  19. 


Sept.  30 


At  omo 
hyoid. 


Aug.  21. 


1,3,4 
day. 


5  days. 


E.  Aneurism  of  caro- 
tid, innominate, 
and  subclavian. 


Nov.  25. 


Day  be- 
fore op- 
eration. 


Nov.  29. 


THE    COMMON    CAROTID    AUTEUY, 


65 


Common  Carotid  Artery — continued. 


Datfl  of 
opei'atioii. 


J3 

13 

o 
u 

a 

o 

a 

ij 

^ 

ho 

^ 

k. 

m 

Tj 

Recovery. 


CaiiHO  of  death, 
date  after  op. 


REMARKS. 


,Tuno  22, 
1H17. 


1S38. 


May  12, 
1,S63. 

May  18, 
L      18(33. 
Sept.  4, 
18W. 

Oct.  7,  1804, 

An^.  4, 
18(35. 


Aug.  9, 
IStfU. 

Oct.  4,  lS2f). 


Sept.  6, 
18i8. 


Oct.  30, 
1S18. 


Dec.  16, 
1812. 


1823. 


1  montli 
later. 

"July  10, 
182"). 


March  4, 

1S27. 


April  .3, 
1S45. 


After K'thday.     Horn 


nth 

day. 


14,  16, 
IVth 
day. 

3d  day. 


4th  and 
10th. 


Often. 


22 


Recovered. 


Kolicf  only 
temporary. 


Recovered. 


Recovered. 


Recovered. 
Recovered. 


Recovered. 

Recovered. 
Recovered. 


Recovered. 

Recovered. 
Recovered. 


Recovered. 


Cured. 


Cured. 


l.Tth  day.     Hera. 


38  hours. 


Next  day. 


Cured. 


Cured. 


Not  cured. 


Improved. 


Worse. 
Cured. 


Slight  im- 
provement. 


2.ith  day.    Hemiple- 
gia.    Coma. 


19th  day.  Hem.  ;  de- 
lir. 


49th  day.     Coma. 


I'ith  day.     Exhaus- 
tion. 


4th  day.     Plenritis, 
pysemia. 

Pth  day.    Diarrhoea. 


Ah  pain  coawed  on  prn«Bnre  ap- 
plied to  left  carotid,  thiH  vesHol 
was  tied.  lielief  was  not  of 
lonu  duration. 

Subclavian  tied  same  time.  Aii- 
topj-y  :  f'arotid  and  innominate 
obliterated  ;  subclavian  open. 
Dixt'il. 

Died  17  months  after  of  disease. 


Both    vessels   were    closed ; 
brain  symptoms  noted. 


Hemiplegia  supervened  on  23d 
day.  Autopsy:  Left  hemisphere 
soft ;  tumor  was  in  vertf-bral  be- 
tween atlas  and  occiput. 

Delirious  after  operation.  Au- 
topsy: Ulcerated  hole  in  carotid 
at  ligature. 


Erysipelas  in  face;  violent  dr. 
lirium  after  oiieration.  Autopsy: 
Arachnoid  sliyhtly  injected; 
brain  normal. 


2  ligs.,  vessel  divided  between 
them  ;  4th  d.  light  side  slightly 
paralyzed,  which  disappeared 
slowly. 


"  Several  months  after  operation 
she  is  said  to  be  doing  well  and 
tumors  subsiding." — Nurrif.-, 

Autopsy:  Pus  in  pleural  sac 
and  mediastinum. 


n  days  paralysis  rig^ht  arm  ," con- 
vulsions ;  paralysis  improved 
later;  mind  impaived. 

After  operation  stupor,  which 
passed  off  in  2  days. 

Ball  entered  angle  left  inf-mav. 
fractu'ing  it;  passed  beneath 
tongue  ;  exit  right  side  of  hyoid 
bone.  On  account  of  continu'^d 
hem.  after  lig.  of  common  caro- 
tid, ext.  carotid  was  ligatured. 

Ten  weeks  after  this  ope:atioa 
subclavian  was  tied  lor  was 
supposed  to  have  been  tied). 
AutoPsy  showed  carotid  obli'- 
erated,  but  subclav.  pervious. 


66 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
opetator. 


Source  of 
information. 


Cause  of 
operation. 


380      Maiaonneuve. 


Arch.  Klin.  Cliir., 
1868. 


do. 

Mandt. 
Marchal,  1835. 

Marquardt, 

1869. 

Marjolin,  1814. 

Maunder,  1861. 

do.        1867. 

Mayer. 

Maunoir. 

Mayo,  Ch., 
1827. 

Mayo,  H.,  1828. 
do.         1834. 

do.         1833 

Mayo,  E.,  1829. 

McClellan, 
1825. 
do. 


do. 
do. 


Norris  Contrib.; 

Arch.  Klin.  Chir., 

1868. 

Allg.  Med.  Zeit.; 
Lancet,  Jan.  1870. 

Norris  Contrib.; 
Arch.  Klin.  Chir., 

1868. 
Arch.  Klin.  Chir., 

1868. 

Lancet,  Sept.  1867. 


Arch.  Klin.  Chir., 

1868. 
do. 

Norris  Contrib.;  Arch, 
cit. 

Norris  Contrib.;  Arch, 

cit.;  Ehrmann  des 

effets. 

do. 


Norris  Contrib.; 
Arch.  Klin.  Chir. 

(cit.). 

Arch.  Klin.  Chir., 

1868. 

Norris  Contrib.;  Arch 

Klin.  Chir.,  1868. 

do. 

do. 


Maurin,  1829. 

McCullough. 

McMurdo,  1846, 


Norris  Contrib.,  1868 

Am.  Jr.  Med.  Sci., 

April,  1864,  p.  334. 

do. 


Y'g 
m'n 


5 
mos 


Varicose  aneur- 
ism of  parietal 
reg.,  traumatic. 


Kemov.  of  parotid 
gland,  prepara- 
tory. 

Prep,  to  removal 
of  fungus  of  pa- 
rotid. 

Hera.;  puncture 
aneurism   mista- 
ken for  abscess. 

Stab  wound  of  ex- 
ternal  carotid 
angle  of  jaw. 

Hem.;  shot  w'd. 


Second,  hem.  after 
removal  of  inf, 
maxilla. 

Innominate  an- 
eurism (sup- 
posed). 

Prep,  to  removal 
of  inf.  max. 

Cirsoid  aneurism 


Tumor  of  neck. 


Hem.;  ulcer  thr't; 
lingual  artery. 

Hem.;    knife  w'd 
of  throat. 


Erectile  tumor  of 
face. 

Hem.;  abscess  of 
thr't  (after  punc- 
ture). 

Erectile  tumor  of 
orbit. 

Erectile  tumor  of 
cheek. 

Vascular  fungus 
of  dura  mater. 


Aneurism  of  caro- 
tid, traumatic. 
Shot  wound. 

Hem.;  abscess. 


2  mos. 


6  days. 


8  days. 


ii  y'rs. 


1  m'nth 
3  days. 
1  day. 


THE    COMMON    CAROTID    ARTERY. 


67 


Common  Carotid  Artery — continued. 


No. 


Dato  of 
operation. 


a 

o 

o 

" 

t>. 

ri 

ts 

^ 

h-i 

a 

Recovery. 


Condition. 


Canse  of  death, 
date  after  op. 


KEMAHKS. 


381 
382 
383 

384 

385 

3S6 

387 

388 
389 

390 

391 
392 


June  19, 
1835. 


1S14. 


March  30, 

1861. 


(?) 
Before  1821 

Oct.  19, 

1828. 


1834. 


Once. 


395 
396 


398 
399 


Twice. 


Jan.  10, 
1825. 
1825. 


Nov.  20, 
1829. 


Dec.  1,1845 


5,  6 
days. 


3d  day. 


Recovered. 


Cured. 


Recovered- 
Recovered 
Recovered 

Recovered 


No  improve 

ment. 

No  better. 


Cured. 


8      Recovered. 


Recovered. 

Recovered. 
Recovered. 
Recovered. 


Recovered, 
Recovered 


Improved. 

Cured. 

Cured. 
Cured. 
Cured. 


Soon.    Cereb'I  com- 
plicatioas. 

Sth   week.     Return 
of  disease. 

6th  day.     Hem.  ; 
cerebral  complica- 
tions. 


Several  days.  Hem. 
meningitis. 


5thi  day. 


13th  day. 
of  brain. 


Inflam'n 


Cured. 
Cured. 


External  carotid  was  tied  first; 
this  li^.  foil  liith  day.  The 
Slip,  thyroid  w;ih  tied  at  this 
time.  Hem.  af,'ain  occurrinjf, 
the  int.  and  common  carotids 
were  tied,  followed  by  complete 
homiplei,'ia  (L).  Autoj)-sy  :  Right 
hemisphere  softened,  tlie  sym- 
pathtitic  nervti inclu/iedin  both 
the  internal  and  common  car- 
otid ligatures. — Pilz. 


External  carotid  was  first  tied, 
but  not  arresting  hem.  common 
carotid  tied  ;  2d  day  convul- 
sions. 

Attempt  to  tie  ext.  carotid  a  fail- 
ure ;  no  cerebral  symptoms  fol- 
lowed. 


Pain  right  side  of  head  for  sev- 
eral weeks. 

Subclavian  also  tied.  Autopsy  : 
Aneurism  of  aorta — not  of  in- 
nominate. 


Died  in  7  months,  of  hem.,  dis- 
ease ;  cerebral  complications  ; 
epilepsy  followed  operation. 

Patient  died  5  years  lat'^r.  Au- 
topsy showed  lingual  artery  to 
have  been  wounded. 

6  days  after  1st  lig.  hem.  oc- 
curred and  a  deeper  lig.  was 
applied  ;  paralysis  of  left  side. 
Autopsy:  Abscess  in  right  hemi- 
sphere. 


7th    day. 
tion. 


Dr.  C.  Pilz  of  Breslau  accredits 
McClellan  with  a  4th  case  un- 
der the  head  of  "  Epilepsy,'"  the 
patient  "  M.  16  R.,  and  vascular 
tumor  over  right  ear,"  leads  me 
to  believe  that  the  case  is  iden- 
tical with  this  case.  I  have 
omitted  it  on  this  account,  with 
many  others  1  have  found  about 
which  an  uncertainty  exists. — 
Author. 

Two  ligatures,  vessel  divided 
between. 


Exhaus-  Autopsy  :  Varicose  aneurism — 
int.  jug.  vein  and  int.  carotid 
artery. 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


IS  3 


p  s 


McGraw,  T.  A., 
Michigan,  1S73 


McKee,  J.  C, 
lS6i,  U.  S.  A. 
McMahon,  A., 
U.  S.  A.,  186S. 
?  U.  S.  A.,  1863. 


Mettauer,  1842. 

do.        1829. 

Michaux,  1846. 
Michels,  1835. 

Miller,  1825. 
do.      1836. 


Moon,  W.  P. 
Molina,  1828. 

Montgomery, 
1829. 


Moore,  J.  H., 
1862. 


416    Moreland,  1861 
Lavallee. 
Morrison,  18i2. 


Moirogh,  1849. 


Morton,  T.  G.. 

Pliila.,  1864.' 

do. 


do.      1869. 


do. 


Letter  to  author  from 
Prof.  McGraw. 


Med.  Surg.  Hist.  Eeb. 

Otis. 

do. 


Ehrmann  des  effets, 
Paris,  1860,  p.  88. 

Am.  Jr.  Med.  Sci., 
Oct.  1849,  p.  349. 

do. 

Norris  Contrib.;  Am. 

Jr.  Med.Sci.,Oct.lS49, 

p.  349. 

do. 

Norris  Contrib.; 

Ehrmann  des  effets  ; 

Arch.  Klin.  Chir. 

Arch.  Klin.  Chir., 

1868. 

See  Morton,  T.  G.  (a). 

Ehrmann  (cit.),  p.  43; 

Arch.  Klin.  Chir.  (cit.) 

Lancet,  1833,  p.  421  ; 

Norris  Contrib. 


Med.  Surs.  Hist.  Reb.; 
Otis. 


Arch.  Klin.  Chir., 

1868. 

Am.  Jr.  Med.  Sci., 

vol.  xlx.  p.  324; 

Norris  Contrib. 

New  York  Journ.  Med 

&  Coll.  Soc,  May, 

1852,  p.  419. 

do. 

Am.  Jr.  Med.  Sci., 
January,  1868. 


Am.  Jr.  Med   Sci., 
April,  1876. 


do. 


18 


Mid 
age. 


Mid 
age. 


Prep,  toremov.  of 
pulsating  malig- 
nant tumor  of  su- 
perior maxilla. 

Shot  w'd  of  left 
mastoid  reg. 

Shot  w'd  of  right 
malar  reg. 

Shot   w'd   of  cra- 
nium   through 
frontal  bone. 


Some 
time. 


Aneurism,  traum. 


Aneurism  anast. 
antrum  of  nose. 

Prep,  to  remoT.  of 
polyp,  throat. 

Aneurism  anast. 
of  face  and  occi- 
put. 

Wound  of  neck. 

Erectile  tumor  of 
orbit. 

Aneurism,  fusi- 
form ;  superior 
thyroid. 

Aneurism  of  as- 
ternal carotid. 

Aneurism  of  caro- 
tid. 


Several 
years. 

About 

1  year. 

2  years. 

27  days. 
18  mos. 


Shot  w'd   of   left 
temporal  bone. 


Pulsating  fungus 
of  dura  mater. 

Aneurism  of  in- 
nom.  and  carotid. 


Epilepsy. 


Spontaneous  an. 
eurism  of  orbit. 

Hem.  2d  day  after 
attempted  remo- 
val of  tumor  of 
neck. 

Hem.;   lacerated 
wound  of  face. 


Supposed  intra- 
cranial aneu- 
rism. 


Pulsating 
of  orbit. 


8-9y'rs. 


Few 
days. 


Above 

omo-hy. 

do. 


Aug.  21. 
April  9. 
Nov.  25. 


Feb.  14. 


I5:  inch 
above 
innomi- 
nate. 


March 
2d,  Sth. 


Several 
times. 


THE    COMMON    CAROTID    ARTERY. 
Common  Carotid  Artery — continued. 


09 


Dato  of 
oporatiou. 


o  t^i  o 

Hod 


Recovery. 


Cause  of  death, 
date  after  op. 


KEMAHKS. 


May  17, 
1873. 


Aug.  27, 

18U4. 

May  7, 1865. 

Dec.  17, 

1803. 


1842. 


May  12, 
li29. 


Nov.  8, 1846. 


March  12, 
183.0. 


Oct.  1825. 
1836. 


March  10, 
1829. 


March  22, 
1862. 


Ang.  7, 
1851. 

Nov.  S, 
1832. 

Feb.  23, 
1849. 

Dec.  4, 

1864. 
1864. 


Oct.  15, 
1869. 


1874. 


Jan.  8,1876, 


12th 
day. 


Several 
times. 


Kecovorod, 


6  days. 
19  days. 
2  days. 


12  days.    Coma  ;  he- 
miplegia. 

12    days.     Cerebral 
complications. 


Recovered. 
Recovered. 

Recovered. 


Cured. 
Cured. 

Cured. 


8    days.      Cerebral 
complications. 

4  days. 


Recovered. 


Cured. 


12.5  days.     ( ? ) 


Recovered. 


Cured. 


11  days.     Pyaemia. 


Recovered. 


Recovered. 


Not  cured. 


Improvem't 
only  temp'y 


10th  day.    Pyaemia. 


21st  day.  Rupture 
jug.  vein  ;  hem.  in- 
direct. 


24  hours.     Cerebral 
complications. 


Few  hours.     Serous 
apoplexy. 


Ball  entered  frontal  bono  1^  in. 

above   tlie  supraorbital  ridge, 

through   right  orbit,    out  near 

angle  of  inf.  maxilla. 
Hemiplegia  (left)  in  eleven  h'rs. 

Autopsy:     Right    hemisphere 

Kol'tcnod. 
Paralysis  (right)  24  hours  after 

operation  ;  8th  day  coma  ;  death 

in  convulsions. 
Died  2  y'rs  after  from  carcinoma. 

Patient  was  3   months  pregnant 
at  time  of  operation  ;  did  well. 

For  3  days  after  operation  patient 
was  unconscious. 
2d  day  ;  paralysis  of  left  side. 


Died  suddenly  ;  no  autopsy. 


Moeller,  see  Gunderlach. 

Tumor  disappeared ;  cause  of 
death  not  given.  (Probably  py- 
aemia.— Author.)  (There  was 
suppuration  of  the  tumor,  and  at 
autopsy  the  int.  jug.  vein  was 
found  involved  in  the  disease. 
DUtril?) 

Six  years  after  operation  there 
was  facial  paralysis.  (In  all 
probability  due  to  direct  injury 
to  7th  nerve  (portio  dura^  by 
missile. — Authnr.) 

Autopsy :  Lower  thrombus  ad- 
herent, upper  not. 

Died  suddenly  20  mouths  after; 
cause  not  given.    Distal. 


Partial  paralysis  of  left  side  fol- 
lowed operation. 


Mediate  transfusion  practised  5 
days  after  operation  ;  patient 
did  well  until  19th  day,  when 
int.  jug.  vein  ruptured  ;  died  2 
days  later. 

Although  the  bruit  was  distinct- 
ly heard  by  Dr.  JI..  no  aneurism 
was  discovered  at  the  autopsy. 
Intense  inflammation  at  apex  of 
orbit  and  firm  clots  in  the  si- 
nuses. 

Autopsy:  Arachnoid  opaque  and 
cloudy  ;  large  amount  of  serum 
beneath;  patient  had  been 
struck  in  this  eye  by  snowball 
29  years  previous. 


70 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

Cl    CD 

c3  eS 

o.S 
t3 

Z   El 
oJ.-r, 

P.2 

<M  bD 

6 

bo 
<1 

"3 

ft  1 

Si 

421 
425 

4?,fi 

Mosely,  N.  E., 
1864,  U.  S.  A. 

Moses,  I.,  1863. 

r  Murdock,  E., 
J  1863,  U.  S.  A. 
]            do. 

'  Mussy,  1827, 
Hew  Hamp- 
shire, 
do. 

'MuUer,  1831. 

'       do.      1832. 

Mott,  Prof.  VaL 
entine,  New- 
York. 

do. 

do. 

do. 

do.  1823. 
do.  1831. 

do. 

•     do.  1850. 

'     do.  1851. 
do.  1852. 

'     do.  1833. 

do. 
'     do.  1858. 

1      do.  1859. 
do.  1855. 

do.  1818. 
do.  1821. 

Med.  Sura:.  Hist.  Eeb.; 
Otis. 

do. 

do. 

do. 

Norris  Contrib.  p.  281; 
Ehrmann  (cit.). 

do. 

Norris  Contrib. 

do. 

Notes  of  the  late  Val- 
entine Mott,  kindly- 
furnished  by  Prof. 
A.  B.  Mott. 
do. 

do. 

do. 

do. 
do. 

do. 

do. 

do. 
do. 

do. 
do. 
do. 

do. 
do. 

do. 
do. 

M. 
M. 

M. 
M. 
M. 

M. 
C'd. 
C'd. 

M. 

M. 

M. 
F. 

F. 

M. 

M. 
M. 

M. 

M. 

M. 
F. 

M. 
P. 

28 

Mid 
age. 

do. 
do. 
20 

20 
4i 
4i 
C'd. 

3 

mos 
60 

45 

Abt 
60 

L. 

E. 

L. 
E. 

E. 

L. 
E. 
L. 

E. 

E. 
E. 

Shot  w'd  of   left 
Inferior  maxilla. 

Shot  w'd  of  face. 

Shot  w'd  through 
larynx  at  upper 
border  of  thyroid 
cartilage. 

Erectile  tumor  of 
scalp. 

do. 

Above 
omo- 
hyoid. 

li  inch 
above 

innomi- 
nate. 

Oct.  27. 
Sept.20. 

Mays. 

Nov.  4. 
Often. 

May  12. 

427 

42R 

, 

4^9 

430 

431 

432 

Aneurism  anast. 
of  orbit  and  nose. 

Aneurism  anast. 
of  neck  and  jaw. 

433 

434 

435 

do. 

Osteo-sarcoma   of 
right  inf.  max. 

Vascular  sarcoma 
extending  from 
occiput  to  clav. 

Lymphatic  gland; 
tumor   of  enor- 
mous size. 

Malignant   tumor 
of  mouth. 

Malignant  fungus 
of  nose, 
do. 

43fi 

437 

438 

439 

50 

21 

49 
17 

L. 

L. 
E. 

L. 
E. 
E. 

E. 
L. 

L. 
E. 

44(1 

441 

44?, 

443 

do. 

Malignant   tumor 
of  antrum,  nose, 
and  zygomatic 
fossa. 

do. 

Malignant  disease 
of  left  orbit  and 
frontal  sinus. 

Rem.  tumor  of 
neck. 

Eemov.  inf.  max- 
ilhi  for  osteo-sar- 
coma. 

444 

445 

446 

447 

448 

2  years. 

THE    COMMON    CAROTID    ARTERY. 


71 


Common  Carotid  Artery — continued. 


Dato  of 
operation. 


ao  o 


Rocovery. 


Condition. 


Cause  of  death, 
date  after  op. 


REMAKKS. 


Nov.  4, 
1864. 


Oct.  23, 
1863. 


May  12, 

1S63. 
May  15, 

1863. 
Sept.  20, 

1827. 

Nov.  2, 

1S27. 
Sept.  13, 

1831. 
Jau.  28, 

1832. 


3d  day. 
5tli  day. 


Op.  failed. 


Recovered. 

Recovered. 
Recovered. 
Recovered. 

Recovered. 

Recovered. 


Not  im- 
proved. 

Improved. 

Not  cured. 


12th  day.    Exhaust. 


2d  day. 


1st  oper.  8th  day. 
2d  oper.  5th  day. 


With 
and 
after 
separa- 
tion of 
liga- 
ture. 


May  21, 
1823. 

Nov.  3, 
1831. 


Oct.  30, 

1850. 

r   Aug.  9, 
1851. 
Jan.  6, 

J      1852. 


Aug.  3. 

1833. 
15  min- 
utes later 
Oct.  5, 

1858. 


June  5, 
I      1859. 
Dec.  1855. 


Nov.  14, 
1818. 


Nov.  IS, 
ISil. 


None. 
do. 


do. 
do. 
do. 


14 


Recovered. 

Recovered. 
Recovered. 

Recovered. 

Recovered. 

Recovered. 
Recovered. 


Recovered 
Recovered 

Recovered 


Hem.   in    about 
days. 


Cured. 


Cured. 


Cured   or 
much  im- 
proved. 
Temporary 
relief. 
Cured. 


Within  48  hours.  No 
hem.     Coma. 


Temporary 
relief. 


Improved. 


Recovered.'      Cured. 


External  carotid  was  tied  19 
days  before  common,  but  failed 
to  arrest  hem. 


Tumor  afterwards  removed,  pa- 
tient lost  2  qts.  blood,  and  more 
than  20  ligs.  wore  required. 


Tumor  had  crossed  bridge  of  nose 
and  invaded  portion  of  opposite 
eye. 


Hemorrhage  was  arterial.    Dis- 
tal. 


Died'one  year  later  from  other 
affections.  Autopsy :  Anenris- 
mal  tumor  was  firm,  small,  and 
solid.    Distal. 

Tumor  removed  day  after  liga- 
ture of  carotid. 


Tumor  of  fauces,  pharynx,  and 
mouth,  immense  size  ;  tumor 
diminished  after  operation. 

Tumor  broke  down  after  1st  op- 
eration, but  returned  in  three 
mouths.  Upon  June  6th,  1S52, 
it  was  deemed  expedient  to  tie 
the  remaining  carotid,  which 
was  done.  (The  notes  are  mark- 
ed underneath  "  successful." — 
Author.) 

Patient  became  comatose,  and 
died  in  this  condition. 


After  last  operation  tumor  sub- 
sided. 


This  patient  died  about  4  months 
after  operatiou.  (I  have  been 
unable  to  find  the  cause  of  his 
death. — Author.) 


72 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


Mott,  Prof.  Val- 
entine, New 
York,  1822. 

do.  1823. 


do.  1830. 

do.  1832. 
r  do. 

i  do. 

do.  18.59. 

do.  1S61. 


(Eve,  Prof. 

P.  F.,  18.3.5.) 

Mott,  v., 

1836. 

do.  1854  ? 

do. 


do.  1834. 
do.  18i9.* 


Mott,  Prof. 
A.  B.,  1854. 

do. 

do.     185,5. 

do.  1856. 
do.  1858. 
do.     18.59. 

do. 
do.     1S6J. 

do.     1867. 

do.     1868. 


Notes  of  the  late  Val- 
entine Mott,  kindly 
furnished  by  Prof. 
A.  B.  Mott. 
do. 


do. 
do. 
do. 
do. 
do. 
do. 

do. 
do. 

do. 
do. 


do. 
do. 


Notes  kindly  furnish'd 

by  Prof.  Mott  to 

author. 

do. 

do. 


do. 
do. 

do. 
do. 

do. 

do. 


P. 

22 

M. 

18 

C'd. 

P. 

19 

M. 

M. 

M. 

19 

M. 

M. 

M. 

M. 

M. 

22 

F. 

6i 

mos 

F. 

7 

F. 

y'rs 
24 

P. 

23 

M. 

6 

F. 

9 

mos 

F. 

2J 

M. 

y'rs 
Mid 

age. 

23 

M. 

Eemovi  inf.  max 
ilia  for  osteo-sar- 
coma. 

Disar.    condyle 
of  inf.  maxilla. 

Aneurism  anast. 

of  temple. 
Remov.  of   tumor 

of  neck. 
Idiopathic  epilep 

do. 

Fungous  tumor  of 
antrum, 
do. 


Bleeding  polypus 
of  nose. 


1  year. 


6  years 


Malignant  di 
of  orbit  ? 
do. 


Epilepsy. 


do. 

do. 


Aneurism  anast. 
of  left  side  of 
face. 

Fungus  hajmatod. 
at  orbit. 

Recurrent  malig- 
nant  tumor  at 
side  of  neck. 

Aneurism  anast. 

Malignant   tumor 
of  parotid. 

Large   aneurism 
anast.  over  paro- 
tid gland. 

Fungus  hsematod. 
of  left  eyeball. 

Shot  w'd  of  right 
antrum. 

Remov.  of  inf. 
maxilla,  malig- 
nant disease. 

Subclavian  aneu- 
rism. 


THE     COMMON    CAROTID    ARTERY. 


73 


Commoyi  Carotid  Artery — continued. 


Date  of 
operation. 


March  30, 
1822. 


May  15, 

1823. 

1830. 
Feb.  1832. 


6  months 

later. 
Juie  1, 

l^-i9. 

ISJl. 


July  25, 
1835. 

Aug.  25, 
1836. 

■     1854  7 

3  months 
later. 


Sept.  H, 

1848. 

Oct.  1834. 

Oct.  30, 

1849. 


Feh.  1,1854. 


April  10, 

1S.")4. 

Feb.  3, 1855, 


Oct.  30, 

lS.i6. 
Feb  8,  185S, 

Jan.  20, 
1859. 

March  27, 

1859. 

Auff.  24, 

1864. 

1867. 


Aug.  13, 
1S68. 


0   OJ 


Condition. 


Eeoovery. 


llocovorcd. 


Recovered. 
Recovered. 
Recovered. 
Recovered. 
Recovered. 
Recovered. 


Improved. 

Cured. 

Slifjht  re- 
lief. 
do. 

Improved. 

Cured. 


Recovered.;  Temporary 

relief. 
Recovered. 

Recovered. 


Recovered. 
Recovered. 


Recovered. 

Recovered. 
Recovered. 

Recovered. 
Recovered. 
Recovered. 

Recovered 
Recovered. 


Improved. 


do. 
do. 


Cured. 

Cured. 
Cured. 

Cured. 
Cured. 
Cured. 

Cured. 


Cause  of  death, 
days  after  op. 


4tli  day.    Tleuritis 
puoumoiiitis. 


4th  day.     ? 


Died  about  1  year  after  of  tuber- 
culosiK  of  lungs. 

Tumur  decreased  notably  after 
operation. 

Dr.  V.  Mott  notes  this  as  his  ."iOth 
case  of  ligature  of  the  cmnion 
carotid.  The  case  was  L'iven 
him  for  operation  by  his  son, 
Dr.  A..  B.  Mott. 

Polypus  returned  after  Dr.  Eve's 
operation,  and  was  removed  by 
him  once  or  twice,  but  recur- 
ring Dr.  Mott  tied  the  vessel  of 
the  opposite  side. 

(Note. — A  mention  of  this  easels 
made  upon  a  little  brown  sheet 
of  paper,  faded  by  time,  found 
among  Dr.  V.  Motfs  MSS.  I  am 
conviii'ed  that  it  has  not  been 
heretofore  given. — Author.) 

The  attacks  were  not  so  violent 
and  at  longer  intervals. 

*  These  31  cases  of  Dr.  Valen- 
tine Mott  are  all  the  eases  in 
which  Dr.  Alexander  B.  Mott 
(who  has  carefully  looked  over 
the  notes  left  by  his  distinguish- 
ed father)  can  positively  state 
the  results  of  the  operations. 
There  are  20  other  cases  where 
mention  is  made  of  tying  the 
carotid,  but  no  results  given, 
nor  indications  by  which  the 
cases  could  be  followed  out. — 
Author. 


Eye  was  extirpated  at  same  time; 
no  return  after  two  years. 


Disease  did  not  return  ;  eyeball 

extirpated  same  time. 
Lieut.  Maley,  5th  U.  S.  Cavalry; 

wound  by  explosive  missile. 


23d    day.     Pulmon.  The  innominate  artery  was  tied 
hem.  I  i^anie    day  :    ligature    loose  on 

20th. 


u 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


o.g 


Mott,  Prof. 
A.  B.,  1874. 


Niccoli,  1850. 
Nieden,  187-t. 


Nason,  J.  J. 
1867. 

Norris,  Geo.  W., 
Phila.,  1855 


Nottingham, 

1841. 

Nunneley,  1852, 


do. 
do. 


1856. 
1858, 


do.        1859 
do. 
do. 


Nussbaum, 
1860. 


do. 
do. 


do. 
do. 


Ossieur,  1848, 
des  Koulers. 


494  O'Reilly,  1844. 

495  O'Shaugh- 
□  essey,  about 

I8i.-:. 


Notes  kindly  furnish'd 

by  Prof.  Mott  to 

auihor. 


Arcb.  Klin.  CMr., 

1868;  Pllz. 

Schmidt  Jahrb.,  B. 

169,  p.  52. 


Br.  Med.  Jr.,  Feb. 
1867  ;  Am.  Jr.  Med. 

Sci.,  April,  1867. 

Pilz  ;  Am.  Jr.  Med. 

Sci.,  April,  1856. 


Arch.  Klin.  Chir. 

1868;  Pilz. 

Med.  Chir.  Trans. 

vol.  xlii.  p.  165. 

do. 

do.  p.  175. 


do. 
do. 
do. 


Bayr.  Aerz.  Intellig. 
Blatt,  1863,  No.  3%  S. 
461;  Arch.  Klin.  Chir. 
(cit.). 
do. 

do.  S.  472. 


do.  S.  470. 
Arch.  Klin.  Chir.. 

1868. 

do. 
do. 


do. 


Dublin  Med.  Press, 
Oct.  1844  ;  Lancet, 
1844,  vol.  i.  p.  470. 
Norris  Contrib.; 
Dublin  Med.  Press, 
Oct.  1844;  Lancet, 
1S14,  vol.  i.  p.  470. 


67 


24 
19 

Boy 

46 


R. 


Malignant  tumor 
of  antrum. 


Knife  wound,  sui- 
cidal. 

Pulsating  tumor 
of  left  orbit. 


Several 
weeks 


Wound  by  pitch- 
fork at  bifurca- 
tion. 

Aneurism  of  caro- 
tid, traumatic. 


Tumor  of  mouth. 

Aneurism  of  orbit 
traumatic, 
do. 

Aneurism  of  orbit, 
spontaneous. 

do. 

Aneurism  of  orbit, 
traumatic. 

Supposed  aneu- 
rism of  orbit 
carcinoma. 

Hem.   of  internal 
maxilla. 


Neuralgia. 

Tic  douloureux. 


do. 
Epilepsy. 


do. 
do. 


Hem.  ;  puncture 
wound  of  verte- 
bral (supposed 
carotid). 


Supposed  aneu- 
rism (carcino- 
ma). 

Supposed  innomi. 
nafe   aneurism 
(of  aorta). 


5  days. 


8  years 


2  years, 


THE    COMMON    CAROTID    ARTERY. 


75 


Common  Carotid  Artery — continued. 


Date  of 
operation. 


•?•  "^  o 

i>  'i  u 

o  0  <a 


d  o  o 


Condition.    Recovery. 


CauHo  of  (loath, 
(layH  after  op. 


UEMARKS. 


July  2, 1850, 

1874. 


Not.  8,1855, 


Oct.  12, 

1874. 


2d  day. 


Jan.  4, 1841 

Nov.  3, 1852 

March  8, 

1836. 

April  3, 

1858. 

Aug.  24, 
1859. 


Recovered. 


Recovered. 
Recovered, 


12 


Cured. 
Cured. 


Cured. 


Several 

times, 

profuse 


Nov.  2, 1860. 


'   March  9, 

1862. 

Oct.  30, 

1862. 

Nov.  8,1862, 


July  20, 
1844. 


After. 


23 


Recovered. 
Recovered. 
Recovered. 


Recovered. 
Recovered. 
Recovered. 


Recovered. 
Recovered. 


Recovered. 
Recovered 


Recovered. 
Recovered, 


Improved. 
Cxired. 


Dr.  Alexander  B.  Mott  has  tied 
the  common  carotid  in  4  other 
instaiiccH,  hut  the  nofcB  of  caHes 
giving  accurate  rosiilt«  could 
not  be  obtaineti  in  time.  Unfor- 
tunately, other  ca>'eH  are  neces- 
sarily omitted.  Th':  author  is 
indebted  to  Valentino  Mott, 
Esq.,  for  valuable  aid  in  collect- 
ing his  father's  and  grandfath- 
er's cases. 


Carholized  catgut  lit-'atnre,  com- 
pression of  carotid  had  been 
tried  forlOwoekH  without  fffect; 
patient  left  bed  6  days  after  op. 


34th   day.    Cerebral  Several  days  after  operation  con- 
complications,  vulsions.     Autopsy  :     Varicose 
I  aneurism   of  internal   jugular 
vein   and   carotid   artery ;    left 
hemisphere  softened. 


No  brain  symptoms. 

16th  day.     Exhans-!Convulsions  day  after  operation, 
tion    and    cerebral 
complications. 


Not  cured. 


Cured. 
Cured. 

? 

No  benefit 
in  either  of 
these  three 
cases;  pro- 
bably in- 
creased vio, 
lence  of  the 
malady 


Autopsy  :  Left  hemisphere  soft- 
ened. 

Very  much  improved  on  October 
10th  following. 


Paralysis  of  left  side  followed 
5th  day. 


2d  day.    Exhaust'n.  No  brain  symptoms 


3d  day.     Hem. 


9th  day.   Apoplexy 


jlOth  day.     Hem. 


Loss  of  sensibility  in  right  arm 
for  14  days. 

Nerve  resected  at  pame  time  ;  12 
hours  after  operation  paralysis 
of  left  side  ;  recovery  complete. 

No  bad  symptoms  followed  op. 

Convulsions  continued,  seeming 
in  some  instances  to  be  exagge- 
rated. 

In  one  case  the  j  ugular  vein  was 
wounded  and  was  tied  or  stitch- 
ed around  some  way  to  arrest 
hemorrhage  ;  pysemia  followed 
with  pleuritis  ;  partly  recov- 
ered ;  "die  heftige  'Blutuiig 
wurde  durch  die  umsehlum- 
gene  naht  gestillt." 

Pressure  over  carotid  arrested 
hemorrhage,  hence  ligature.  (It 
is  probable  the  vertebral  was 
compressed  with  carotid. — Au- 
thor.) Autopsy  :  Wound  of  ver- 
tebral . 

Autopsy  :  Carcinoma  ;  brain  not 
examined. 

Autopsy  :  Rupture  of  aneurism 
of  aortt ;  innominate  almost  OD- 
literated. 


76 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


PATIENT. 


Cause  of 
operation. 


Packard,  J.  H.^Med.  Surg.  Hist.  Reb.;   M 


1864. 

Pallau,  Prof. 

M.  A.,  1861. 


Palmer,  H., 
1863. 


Parsons,  1846. 
Partridge,  1864, 


Patruban. 


do. 
do. 


do. 
do. 


Pauli?     Butcli- 
ev?    Geigens? 
Parker,  Prof. 
Willard,  1848. 


do.        1851. 
do.        1S54. 

f  do. 

do. 

do.       18.'55. 


Otis, 

Verbal  com.  to  author 
(army  of  W.  Va.). 


Arch.  Klin.  Chir., 

1868. 

Med.  Surg.  Hist.  Reb. 

Otis. 


Am.  Jr.  Med.  Sci., 
1848,  p.  3o0. 

Lancet,  Dec.  1864,  p. 
6.59. 


M. 


AHg.  Wien.  Med."       F 

Zeit.,  1876,  No.  48,  SO; 

Am.  Jr.  Med.  Sci., 

April,  1877. 

do. 


do. 
do. 


do. 
do. 


do. 
do. 


Schmidt  Jalirb.  No. 

134,  p.  308. 

From  notes  of  cases 

kindly  furnished 

author  by  Prof. 

Parker. 


do. 
do. 


do. 
do. 


Mid 
age. 


19 
21 

Girl 

63 
41 

37 


Y'g 
m'n 


23 


Shot  w'd  of  right 
jaw. 

Buckshot  wound; 
fracture  of  ra- 
mus of  inf.  max. 


Prep,  remov.  inf. 

maxilla. 
Shot  w'd  of  right 

side  of  neck  and 

ear. 


Pain  in  head. 


2  years. 


Stab  with  knife  ;  6  days", 
wound  of  left  ex- 
ternal carotid- 


Tic  douloureux. 

do. 
do. 
do. 

do. 
do. 


do. 
do. 


Shot  wound  of  oc- 
cipital artery. 
Epilepsy. 


Fibroid   tumor  of 

nose. 
Malig.   tumor  of 

face. 


L.    Malig     dis.   an- 
trum. 


Hem.   ext.    caro- 
tid. 


14  days 


6  mos. 


7  mos. 


Sept.  30. 


July  2, 
1863. 


Above 
omo- 
hyoid. 


do. 
do. 


do. 


Below 
omo- 
hyoid. 


July  12. 


THE     COMMON    CAROTID    ARTERY. 


77 


Common  Carotid  Artery — continued. 


Date  of 
operation. 


a  o  o 

o  S  <^ 

"  c-'* 

<D  o  ee 

Condition. 


Recovery. 


OauBO  of  death, 
days  after  op. 


JIK.MAUK.S. 


Oct.  21, 

1S64. 

Jnne,  1861. 


July  13, 

isra. 


April  i 
1864. 


After. 


lOth 
day. 


Nov.  8, 
IS-iS. 


July,  1851. 

April  15, 
1854. 

May  6, 
1854. 


I     Jan.  7, 
L      1854. 
Jan.  3, 1855. 


29  th 
day, 
con- 
trolled 
by  pres- 
sure. 


None. 
do. 


do. 


'  ay. 
None. 


Recovered- 


Recovered. 

Recovered. 
Recovered. 
Recovered. 

Recovered. 
Recovered. 


Recovered. 


Recovered, 
Recovered. 


Recovered. 
Recovered. 

Recovered. 


Recovered. 
Recovered. 


Next  day.     (?) 


Cured. 


(Partial  not 

permanent.) 

Cure  for  8 

months. 

(?) 


Benefit 
temporary. 


Greatly  im 
proved. 


Much  bene- 
fited 
Not  cured. 


No  benefit. 


No  benefit. 
Cured. 


3d  day. 

Next  day.     Ilem. 


29th    day. 
of  glotti.s 


Died.     Pyjemia. 


13  days  after  operation  patient 
was  ''sittini,'  up"  in  the  hospi- 
tal  ward,  in  every  way  doiug 
well. 


Autop.sy  :  Ball  lodged  against 
atlas,  wliich  latter  was  frac- 
tured and  |)rcs.'^ed  against  ver- 
bral  artery  ;  internal  carotid  cut 
almost  in  two  at  canal;  medulla 
uninjured. 

Improved  at  first ;  soon  as  pain- 
ful as  ever  ;  died  in  few  months 
of  malady. 

Wound  behind  anple  of  jaw; 
hemorrhage  ceased  after  liga- 
ture; April  2(;th  rigors.  Autop- 
sy; (Edema  glottidis  ;  conge.s- 
tion  of  lungs ;  large  absce-'ss 
behind  jaw. 

No  recurrence  in  6  years. 


Relapse  into  previous  condition 
after  4  years. 

Cessation  of  pain  for  8  months, 
then  return  of  malady. 

Died  two  years  after  last  opera- 
tion from  carcint  ma  ;  neurect'^- 
my  had  been  performed  14  years 
before,  giving  relief  to  near  date 
of  ligature. 

Disease  relapsed. 

Relapsed  in  11  months  (this  man 
was  playing  cards  in  a  C"/i  six 
hours  after  this  ligature  wa-i 
applied). 

Resection  of  the  nerve  had  been 
twice  performed  with  only  tem- 
porary relief;  slight  cerebral 
symptoms  for  some  weeks ; 
passed  off. 


Patient  had  been  trephined  by 
Prof.  P.,  and  a  depres.sed  spicu- 
luni  of  bone  removed.  Improved 
after  this  for  a  time,  when  at- 
tacks recurring  the  carotid  was 
tied.  Patient  removed  to  a  farm, 
the  epilepsy  ceased  and  he  died 
of  some  other  affection  27  years 
later. 

Patient  seen  nine  years  later ; 
was  very  comfortable. 

Patient  survived  op.  some  time. 
Removed  to  country,  where  he 
died.     (Disease  returned.) 

Patient  died  about  r,  months  after 
op.  from  hemorrhage  and  ex- 
haustion, the  two  ve^sels  liga- 
tured having  an  interval  of  .^3 
days. 


Internal  carotid  was  tied  same 
time,  as  the  hem.  was  not  en- 
tirely arrested  by  the  1st  op. 
The  ulceration  was  due  to  the 
corrosive  application  of  a  quack. 


78 


PEIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


aI 


Parker,  Prof. 
Willard,  1856. 


18o2. 
1857. 


639 
640 


do.       1861. 
do. 


do.      1864. 


From  notes  of  cases 

Isindly  furnished  by 

Prof.  Parker. 

do. 

do. 

do. 

do. 


do. 


10 

mos 

60 


38 


do. 

Pearce,  H., 

1863. 

Pearse,  G.E.L. 

1871. 

Peace,  1844. 

Peixoto,  1851. 


Peck,  0.  W., 

1864,  U.  S.  A. 
Perry,  1820. 

Petrequin,  1845. 
Peugnet,  E., 

1861. 
Pique  Dupuy- 
tren  (San  Fran- 
cisco), 1872 
Pirogoff, 
1843. 


do.  1844. 
do.  1837. 

do. 

do. 

do. 
do. 
do. 

do. 


do. 

Med.  Surg.  Hist.  Keb. 

Otis. 

Lancet,  March  16, 

1872. 

Norris  Contrib. 

Arcli.  Klin.  Cliir., 
1868. 


Med.  Surg.  Hist.  Reb.; 

Otis. 

Norris  Contrib, 

do. 

N.  Y.  Med.  Record, 

Jan.  29,  1876,  p.  81. 

Pacific  Med.  &  Surg. 

Jr.,  Aug.  1872;  N.  Y. 

Med.  Kec,  Dec.  1872. 

Arch.  Klin.  Chir., 

1868. 


Norris  Contrib. 

Aroh.  Klin.  Chir. 

1868. 
do. 

do. 
do. 
do. 


Mid 

age 

55 


Mid 

age 
30 


44 


20 

9 
mos 
Mid 
age 


Traum.   aneur. 
ext.  carotid. 

Malig.  dis.  ant. 
Erect,  turn.  face. 

Extensive  vase, 
turn.  face. 

Malig.  turn,  an- 
trum. 


Malig.    dis.   an- 
trum. 


4f  y'rs. 


10 

months, 


2i 
years. 


Above 
omo- 
hyoid, 
do. 
do. 

do. 

do. 


do. 


do. 

Shot   wound    inf. 

max.  and  throat. 
Hem.  ;    carcin. 

tongne. 

Hem.  ;   ulcer  of 
jaw. 
Turn,  of  ear. 


Shot  wound  left 
side  face. 
Aneurism. 


do. 


Hem.; 

several 
days. 


At  omo- 
yoid. 


L.    Erect,  turn,  orbit. 
Shot  wound  left 
antrum. 
Aneur.  carotid. 


Hem.;     aneurism 
anast.  of  occipi- 
tal and   temp, 
region. 


do. 

Erect,   turn,   occi- 
put. 

Hem.;  aneurism 
anast. 

Shot   wound 
(military), 
do. 
do. 

Hem.;  aneurism 
anast. 


2  years 
5  mos. 


Low 
down. 


At  omo- 
hyoid. 


Dec.  3. 


June  19. 


Hem.   facial   ar- 
tery ;  remov.  en- 
chodroma  pare. 


Low 
down. 


July  21, 
1861. 


July  24, 
25,  27. 


THE    COMMON    CA'ROTID    ARTERY. 


79 


Common  Carotid  Artery — continued. 


No. 


Dato  of 
operation. 

^  £  o 

o  g  fe 
0)  O  o3 

w 

Recovery. 


CondUion. 


Cauoe  of  death, 
date  after  op. 


REMARKS. 


518 
519 


620 
621 


522 


623 
524 
626 

526 
627 


Mays,  1556. 


Dec.  13, 1852 
April  6, 

lS-)7. 
April  29, 

ism. 

May  29, 
1861. 


OcL  12, 

1S64. 


530 
531 


532 


Nov.  9, 
1864. 
Dec.  3, 1863 


Nov.  14, 
1851. 


July  6,1864. 

Nov.  IS, 

1820. 

June  5, 1845. 

July  27, 

1861. 

1872. 


533     r    Jan.  16, 
1S43. 


534 

635 

636 

637 

638 
639 
640 


Jan.  9, 

1844. 

Jan.  26, 

1837. 


None. 


do. 

18th 
day. 
None. 


12th 
day. 


After. 


46th 
day. 


12 


Recovered. 


Recovered. 
Recovered. 


Recovered.    No  benefit 


Disease  not 
arrested. 


Recovered. 


(Oc- 
curred.) 


Recovered. 


? 

Cured. 


Improved. 


Cured. 


Died.     Exhaustion. 


5th  day. 

30th  day.     Disease. 


3l8t  day.     Hem. 


Recovered. 
Recovered. 


Recovered. 


Recovered. 


Recovered. 


Cured. 
? 


Cured. 


Improved. 


Cured.    (?) 


6th  day. 


Punctured  wound,  fragment  of 
iron. 

Died  heforo  neparatlotj  of  lig. 

Ileiii.  on  Ihth  day  controlled  by 
moderate  prf^KHuro. 

ycarH   after  op.   patient  was 
perfectly  well. 

IloHpital  patient;  diheaso  was 
not  arrested ;  died  some  tirao 
after  op.  from  return  of  the  ma- 
lignant affection. 

Hospital  patient;  2d  lii,'ature 
was  not  tightened  until  patient 
was  fr.)m  under  the  influence  of 
the  anajsthotic,  and  then  with 
caution.  Hem.  10-12lh  day,  from 
blowing  his  nose:  controlled 
by  pressure  ;  2  weeks  aftf-r  last 
op.  patient  left  for  his  home. 
Since  finishing  thii^  pajier  I 
have  another  case  in  whieh 
Prof.  Parker  tied  the  common 
carotid  and  subclavian  and  ver- 
tebral at  same  time  for  subcla- 
vian aneurism.  The  ^patient 
died  of  hem.  on  the  42d  day. 


A  temporary  ligature  was  placed 
around  the  innominate  as  a  pre- 
cautionary measure,  and  re- 
moved. (This  is  given  by  some 
authors  as  lig.  of  innominate. 
— Author.) 

Hem.  after  operation  controlled 
by  pressure. 


11th  day.  Exhaust'n 


Recovered. 


117th  day.     Hem. 


Died. 

Died. 

Died. 

Died.    Hem. 


At  6  years  of  age  small  tumor  of 
scalp.  In  1S43,  attempt  to  re- 
move it  resulted  in  such  alarm- 
ing hemorrhage,  that  P.  tied 
carotid.  Tumor  not  entirely 
disappearing  by  following  year, 
remaining  carotid  tied.  Tumor 
was  then  treated  by  compress 
and  cured. 


Child  was  doing  well ;  mother 
removed  beyond  reach  of  surgi- 
cal interference  when  hem.  oc- 
curred, causing  death. 


80 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
iaformation. 


PATIENT. 


Cause  of 
operation. 


.9  % 
^■3 


Pirogoff,  1837. 
do. 

do. 

Pitha,  1840. 

do.     1854. 

Pope,  Ch., 
1860,  St.  Louis 


Porter,  1829. 

do.     1838. 

Porta,  1842. 

Post,  Prof. 

A.  C,  N.  Y., 

1845. 

do. 

do.  1862. 


Post,  Wriijfht, 
1813  or  1816  ? 


Priohard,  1862. 


Preston,  1830, 

East  India. 

do.  1831. 


do. 
do. 


Arch.  Klin.  Chir. 

1868. 
do. 


do. 

do. 

do. 

St.  Louis  Med.  &  Surg 

Jr.;  Am.  Jr.  Med.  Soi., 

April,  1864,  p.  556. 


Norris  Contrib. 

do. 

Arch.  Klin.  Chir., 

1868. 
Letter  to  author. 


do. 

do. 

do. 

V.  Mott  ;  N.  T.  Med 

Jr.,  July,  1857;  Trans. 

Phys.  Med.Soc.,voLl  ; 

Norris  Contrib. 

V.  Mott;  N.  Y.  Med 

Jr.,  July,  1857. 


Brit.  Med.  Jr.,  April 
18,  1863. 


Norris  Contrib. 

Lancet,  1831,  vol.  ii. 
p.  648. 

Norris  Contributions, 
etc. 


do. 
do. 


Mid 
age 
Mid 
age. 

Mid 
ai;e. 
Old 
m"n 

8 


Aneur.    innomi- 
nate. 

do. 


do. 
Hem.  mouth. 

Prep,  remov.  sar- 
com.  parotid. 

Hem.  ;    arrow 
wound. 


Aneurism, 
do. 

Aneur.    carotid  ; 

subclav.  innom. 
Telangectasis 

right  cheek. 


Malig.  dis.  tonsil. 

Shot  wound  ext. 
carotid,  high  up. 

Prep,   to   remov. 
sup.  max. 

Pulsat.  tumor  an- 
gle of  jaw  ;  an- 
eur. 

Gland,  turn,  neck; 
supposed   aaeu 
rism. 


Hem.  ;   stab  w'd 
carving-knife, 
vertebral  artery. 

Hemiplegia  of 
left  side 
Epilepsy. 


Epilepsy  and  he- 
miplegia. 


do. 

Paralysis,    par- 
tial, left  arm  and 
leg  ;    loss  vision 
in  right  eye. 


5  w'ks. 


15  y'rs. 
5  w'ks. 


Many 
years. 


Some 
time. 

24 
hours. 


7  days. 


Im'nth, 


6  years. 
Paraly- 
sis for 
last  20 
days. 


Aug.  23, 
1862. 


THE    COMMON    CAROTID    ARTKRY. 


81 


Common  Carotid  Artery — continued. 


Date  of 
operation. 


P  f-"  •— 

O   S    (P 


>(=^ 


Recovery. 


Condition. 


Sept.  1 6, 
1800. 


Aug.  21, 

1829. 

Sept.  22, 

1838. 

1842.  ? 

April  1, 
184.5. 


1S4.'5. 
1862. 


Jan.  9,  18\>i, 
or  1816. 


Sep.  5,  1862. 


Nov.  22, 

18:W. 
Feb.  4, 

IS.Sl. 

r  Aug.  23, 
I       1831. 


Nov.  14, 
1831. 
f    Sept.  2, 
1831. 


563  I  LOct.lO,'.31 


Oc- 
curred. 


After. 


Sth, 
14th, 
loth 
day. 


16-18 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Recovered. 


Recovered. 
Recovered. 

Recovered. 

Recovered. 
Recovered. 


Slictht  im- 
provomeut 
do. 


Cured. 


Cured. 


Cause  of  death, 
date  after  op. 


RKMAUK3. 


3  weeks.  Cerebral 
complication.s. 

intb  day.  Hoin.  ;  as- 
phyxia. 


Cured. 
Cured. 


Temporary 
improvem't 


Improved. 


Not  cured 
nor  inipr'd. 

Improved 
temporarily 


6  week.s.     Hem. 


Died.     Phlebitis  ; 
pya3mia  ;  delirium 


3d  day.     Disease  ; 
cerebral  oomplica. 

A  few    hours.     Ex- 
haustion. 


Autopsy:   One  hemi-pViero  soft- 
ened partially. 
Autopsy:  Polypus  in  larynx. 


The  arrow  was  driven  throu)?li 
left  sup  m-.ix.  and  was  extriict- 
ed  with  (lifficulty  ;  :'>  week*  la- 
ter, on  account  oi'  hem.  tho  car- 
otid was  lied  ;  the  "unfleasaut 
fulness"  remained  after  reco- 
very until  death  of  the  patient 
(Gen.  Bayard)  in  the  battle  of 
Gcttysliui'g,  3  years  later. 

Sao  burst  about  4  montlis  after 
ligature. 


20th  day.     Hem. 


Recovered.     Improved 


Autopsy  :  Two  phlebolitbs  were 
found  in  tumor,  l^h  ebitii  of 
int.  jugular,  although  vein  was 
not  wounded  in  the  operation. 
Pus  in  vein. 

Paralysi^  ensued. 

Int.  carotid  also  tied  at  same 
time  ;  hem.  arrested  ;  patient 
exhausted  by  previous  hem. 

No  cerebral  symptoms  followed. 

No  cerebral  symptoms  noted. 


Died  2  or  3  years  later  from  iri- 
j  tation  of  larynx  by  pressure  of 
I  tumor.  Autopsy:  Tumor  was 
an  enlarged  gland  and  was  rest- 
I  ing  on  the  carotid. 
Aut'psy :  Vertebral  wound  at 
edge  of  foramen  magnum. 


April  13th,  no  return  of  attacks  ; 
patient  much  improved  in  gen- 
eral health. 

On  the  ]-)th  of  Feb.  1832,  he  was 
again  admitted  in  a  state  of  in- 
sensibility aud  had  been  speech- 
less for  14  days.  Jan.  1833,  suf- 
fering from  paralysis  agltaus. 


2.T  days  after  1st  opei-ation,  this 
man  walked  r>  miles ;  on  ac- 
count of  heat  (it  is  supposed) 
the  disease  returned,  and  the 
2d  operation  was  performed. 
Preston  is  accredited  with  oje 
other  case  of  double  ligature 
for  epilep.-^y.  but  I  am  of  the 
opinion  that  it  is  a  repetition  of 
one  of  the  cases  here  given,  at 
least  the  comparison  is  suspi- 
cious and  details  are  lacking. 
— Authur. 


6 


82 


PRIZE    ESSAY. 


Surgical  History  of  the 


No. 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


%- 

o 

<«  d 

a  6 

0  >> 

■-E  B 

d   SJ 

5  =1 

^a 

fi 

tS 

pa 


564 
565 


568 
569 

570 

671 


573 
574 

575 

576 


Randolph,  1833. 

Ray,  E.  R., 

18B4. 


Raynaud,  1871, 


Remer 
(Breslau). 

Reese   D.  M., 

1S23. 

Reyburn,  Robt. 

1866. 

Reynold,  W.  B. 
U.  S.  A.,  1861. 


578 
579 

580 
581 
582 

583 
684 

685 

686 
687 


Richardson, 

W.  F.,  186J. 

Ricliet. 


Kichter. 
Reed,  F.,  1854. 


Rigen,  1829, 
Amsteidam. 


Rivington,  W., 

187."). 
f  Robert,  1846 


Norris  Contrlb. 


Med.  Times  &  Gaz.,      M. 
Feb.  I8B0,  p.  171. 


Gaz.  des  Hop.,  1871, 
p.  425. 


Arch.  Klin.  Chir., 
1S6S. 


N.  Y.  Med.  Jr.,  1857; 

Jas.  R.  Wood. 

Am.  Jr.  Med.  Sci., 

July,  1868. 

Med.  Surg.  Hist.  Reb. 
Otis. 

do. 


Arch.  Klin.  Chir.  (cit.) 


Med.  Surg.  Hist.  Reb. 

Otis. 

Ehrmann,  de.*  effets 

Arch.  Klin.  Chir., 

1868. 
do. 

do. 


do. 
do. 


1847. 

1857. 


Robbins,  N.  A., 
U.  S.  A.,  1864. 

Robertson,  1837. 

Robinson. 

r      Rodgors, 
J.  R.,  1844. 

I    (Van  Buren, 
J  18.50.) 

Rogers,  D.  L., 

1832. 


do. 


Med.  Chir.  Trans., 

vol.  Iviii. 

Ehrmann,  des  effets, 

etc.;  Arcli.  Klin.  Chir. 

(cu.). 

do. 

Arch.  Klin.  Chir., 

1868. 

Med.  Surg.  Hist.  Reb.; 

Otis, 

Norris  Co'ntrib. 

Arch.  Klin.  Chir., 

186S. 

Schmidt  Jahrb.,  B. 

98,  S.  77; 

Archiv  fiir  Klin. 

Chir 

do. 


Norris  Contrib. 


Mid 
age. 

62 

42 

11 


Anenr.  varix. 

Hem.;  malig.  tu- 
mor. 


Hem.  ;  shot  w'd 
neck  ;  ext.  or  int. 
carotid. 


Hem.;  cancer  of 
neck  and  face. 

Rem.  turn.  neck. 

Aneur.  (near  bi. 
fur.  com.  caro- 
tid). 

Shot  w'd  mouth. 


Shot  w'd  neck. 


Hem.  ;  remov. 
turn,  parotid  : 
f-icial  artery. 

Shot  w'd  neck  be- 
hind left  ear. 

Shot  w'd  parotid 
region. 

Hem.  (after  arano 

plastic  op.). 
Tumor  neck   and 

face. 

Innom.  aneur., 
supposed. 


Intraorbital  aneu- 
rism, traumatic. 

Aneur..  cir.^oid, 
frontal  region. 

do. 

Aneur.,  cirsoid. 

Shot  w'd  near  left 
ear. 

Aneurism. 

Hem.  from  ab- 
scess. 

Aneur.  by  anast., 
head. 

do. 

Erect,  turn  face. 


4  days. 


7  days. 


1  year. 
19  y'rs. 


19i 
years. 


2  mos. 


8  mos. 


Below 
omo- 
hyoid. 
Above 
omo- 
hyoid. 


11th 

and 

14(h 

month. 


Nov.  30.    Dec.  6 


Oct.  7. 


Below 
omo- 
hyoid. 


Oct.  16 


Before 
opera- 
tion, 
exces- 
sive. 


THE    COMMON    CAROTID    ARTKRY. 


Common  Carotid  Artery — continued. 


Dato  of 
operatiou. 


s  =  s 

"  >'S 

Recovery. 


Condition. 


Nov.  14, 
1S04. 


Dec.  6,1871, 


1823. 
1866. 


Sept.  19, 
1864. 

Oct.  9,  1864. 


Feb.  22, 

1865. 


Nov.  20, 
1865. 

May  31, 
1854. 

Feb.  21, 
1829. 


1875. 

Jiine  5, 
1846. 

Feb.  22, 

1847. 
1857. 

Oct.  29 
1864. 

March  21, 
1837. 


r      1844. 


687       Dec.  12, 
1        1832. 


Doc.  2d. 


2d  &  3d 
days. 


Noue. 
Profuse 


After. 


Recovered. 
Recovered. 


Recovered. 


Recovered. 


Recovered. 
Recovered. 

Recovered. 


Recovered. 


Recovered. 

Recovered. 
Recovered, 


Cured. 


Cured. 


Cured. 


Marked  im- 
provement. 


Cured. 


Not  cured. 

Not  cured. 
Cured. 


Cause  of  death, 
dato  after  op. 


REMARKS. 


No.xtday.     Corobral  Coma  soon  after  operation. 
compUcatiouH.  I 

17th  day.     Iloiii.  ;      Autopsy ;  No  clot   in   the  artery 
erysipolaH.  |  below  lii^ature  ;   no  artoria  in- 

noiniiiata,  the  carotid  and  Hub- 
clavian  direct  from  the  aorta. 
(I  liavc  nover  seen  this  anom- 
aly.— Author.) 
4th  day.  E.xhans-  No  cerebral  syinptomK  ;  patient 
tion.  was  tranHfused  aft'T  Hu(r<;ring 

from  severe  hemorrhage,  Ur. 
Raynaud,  with  gcnerou.s  devo- 
tioii  to  duty,  furnisliing  the 
blood  from  liis  own  arm. 


24  hours.     Exhaus- 
tion and  disease. 


17th  day. 
Next  day. 


Actual  cantery  had  to  be  used  to 
arrest  hem.  after  operation. 


Hemorrhage    before     operation 
had  been  very  profuse. 


Same  day.   Exhaus-  Hemorrhage  for  4   days   before 
tion,  liem.  operation. 


2d    day.     Cerebral 

complications. 
Sth  day. 


A  few  days. 
4th  day. 


4th  day.  Exhaust'n. 


Autopsy:  No  thrombi  in  artery  ; 
brain  ansemic. 

Tth  day,  paralysis  of  right  leg. 
Autopsy  :  Extravasation  of 
blood  at  base  of  brain. 

Patient  died  of  another  disease 
4  months  later:  tumor  was  on 
arch  of  aorta,  was  diminished 
in  size,  hard,  and  filled  with  a 
firm  coagulum.  Patient  was 
operated  upon  for  hernia  in 
May,  about  one  month  before 
his  death. 

No  cerebral  symptoms. 

Slight  cerebral  symptoms  fol- 
lowed each  operation,  but  pass- 
ed away. 

In  May,  1850.  there  was  no  pul- 
sation in  the  tumor. 


Temporal  artery  was  also  tied. 


See  Van  Buren. 


84 


PRIZE    ESSAY. 


Surgical  History  of  the 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

Is 

^M 

>< 
a 

CO 

!J0 

< 

6 
m 

ft  a 
j3 

588 

Eompani,  1841. 

Romaglin, 
1S34.  ? 

Arch.  Klin.  CMr., 

1868. 
do. 

M. 
M. 

70 
20 

R. 
L. 

Aneur.  carotid. 

Stab  wound  verte- 
bral. 

589 

590 

Roser,  1852. 

Eossi,  1844. 
De  Rouleurs. 

do. 

Ehrmann  de,s  effets  ; 
Arch.  Klin.  Chir,  (cit.) 

M. 
M. 

55 

L. 
R. 

Hem.  after  resec- 
tion. 

591 

See  Ossieur. 

592 

Koux,  1830. 

Quarante  annees  de 
Prat.,  vol.  ii.  p.  401. 

M. 

30 

R. 

Shot  w'd  ext.  car- 
otid or  branches, 
through  month. 

8  days. 

593 

do.     18.«. 

do.  p.  325. 

P. 

46 

L. 

Hem. ;   w'd   ext. 
carotid  ;    fell   on 

June  23, 
1852. 

594 

do.     1837. 
do.     1829. 

do. 

do. 

do. 

Arch.  Klin.  Chir., 
1868. 
do. 

do. 

F. 

M. 
M. 
M. 

30 
26 
45 
33 

R. 
R. 
R. 

glass  vase. 
Remov.   tumor  of 

parotid. 
Aneur.  orbit. 

Rem.  turn.  neck. 

Rem.  tum.  of  an- 
trum, prep. 

2  years. 

595 

596 

6  mos. 

598 

Sands,  Prof. 
H.  B.,  New 

York,  1868. 

New  Yorlf  Med.  Rec, 
Dec.  1869. 

F. 

R. 

Aneur.   root  of 
neck    (supposed 
innom.) 

699 

do.     1869. 

do. 

do.     1870. 

Notes  of  cases  kindly 

furnished  by  Prof. 

Sands. 

do. 

do. 

M. 

F. 
F. 

50 

R. 

Recur,   epithelial 
cancer  in  right 
cheek. 

Above 
omo- 
hyoid. 

601 

40 

R. 

Second,  hem.  after 
remov.  tumor  of 
neck. 

602 

do.     1871. 

do. 

P. 

28 

R. 

Aneur.  com.  caro- 
tid. 

Below 
omo- 
hyoid. 

603 

do.     1872. 

do. 

M. 

53 

L. 

Secondary  hem.; 
removal  of  inf. 
maxilla. 

Just  be- 
low bi- 
furca- 
tion. 

601 

do.     187.0. 

do. 

F. 

39 

R. 

Tumor  orbit. 

Below 
omo- 
hyoid. 

605 

do. 

THE    COMMON    CAKOTID    ARTERY. 


85 


Common  Carotid  Artery — continued. 


No. 

Date  of 
operation. 

Hemorrh'ge 
occurred 
after  op. 

RESULT. 

UEMAKKB. 

Recovery 

Condition. 

Cause  of  death, 
date  after  op. 

fi88 

Oct.  ,30, 

1S44. 
1834  I 

1852. 
1S44. 

1830. 

June  2,<5 
1862. 

June  19, 
1837. 
1829. 

3  times. 
After. 

20tli  day.     \\<-m. 
Diod.     Hem. 

6th  day. 
6th  day. 

riSQ 

(Some  authoTK  think  the  ligature 
wiiH  removed  after  il  was  dis- 
coverod    that    the    hemorrhHffe 
was  not  controlled  by  it.     The 
ligature    once   apfilied    tlglitly 
would  act  as   does  Prof    Fleet 
Spier's  conntriolor,  milking  the 
case    practically    a   ligation. — 
Avthiir  ) 

Paralysin  of  right  side.     Autop- 
sy: Cancerous  deposits  in  lungs. 

Mn 

.wi 

fifl^ 

14-18- 

19thday 

once. 

18 
18 

Recovered. 
Recovered. 

Cured. 
Cured. 

top.sy:   Left   carotid    and    right 
vertebral   also  occluded  ;  only 
vessel  going  direct  to  bi  ain  was 
left   vertebral.     (Analogous   to 
Dr.    Hutchison's     case,    which 
see.)  Difital. 

No  hemorrhage  until  8  days  after 
injury;  actual  cautfry  ;  2  liga- 
tures  applied  ;    no   bad   symp- 
toms. 

Hem.  on  July  Tth,  beyond   liga- 
ture ;  also  on  the  ISth  and  19th 
days  ;  compress. 

ws 

,')!)4 

]4th  day. 

7th   day.     Purulent 
infection.     ( ? ) 
60  hours. 

fiP,-) 

Recovered. 

Not  cured. 

fiPfi 

fi97 

Lig.  was  taken  off  after  48  hours. 
Autopsy:    Congestion  of   right 
hemisphere. 

Died  13  months  after  operation. 
Autopsy:  Aneurism  of  arch  of 
aorta  in  front  of  origin  of  arte- 
ria  inuominata.     This  last  ves- 
sel not  involved.    Dista'.    Sub- 
clavian tied  same  time,  3d  divi- 
sion. 

Hemiplegia  of  opposite  side  12 
hours  after  operation. 

-iflS 

July  16, 
1868. 

May  23, 
18o9. 

42dday. 

23 

Recovered. 

599 

4th    day.     Cerebral 
complications. 

Few  hours.     Hem.; 
exhaustion. 

fion 

Recovered. 

(?) 

KOI 

April  29, 
1870. 

June  23, 

1871. 

Nov.  1, 

1872. 

April  14, 
1875. 

After. 
None. 

Autopsy  :  Ulceration  of  common 
carotid  near  bifurcation.  (Note. 
— The  hem.  had  been  very  pro- 
fuse before  Dr.  S.  arrived  ;  no 
anaesthetic.) 

"Patient  recovered  with  slight 
paralysis,   which   came  on    19 
days  after  operation." 

602 

25 
14 

21 

Recovered. 
Recovered. 

Recovered. 

603 

rism.  Slight 
paralysis  of 
op.  side. 
Cured. 

"  Tumor 

continued  to 

grow." 

fl04 

22,    the  external    tarntid  was 
tied,     Nov,   10,   alarming  hem, 
from  ulcerated  opeuing  of  in- 
tf.rnal  caroVd.     This  was  tied 
above  and  below  opening,  and 
the  common  carrtid  j  ust  below 
bifurcation     Ligature  from  int. 
carotid    came    away    9ih    day. 
The  internal  jugular  vein  was 
tied  with  a  lateral  ligature. 
2  days  after  operation  pulsation 
in  tumor  returned.  Patient  had 
tumor  removed    from    orbit  in 
If 64,  and   a  second    tumor  and 
the  eye  removed  in  1873  :  6  mos. 
after  this  the  third  appeared. 

605 

86 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


Santesson,  18.53. 


Savory,  1871.  (?) 


Sedillot,  1842. 


Sisco,  1829. 


Solly,  186? 
(&  Garroway). 


do.  1853. 

South,  1856. 

do.        ? 

Southam,  1864. 

Surrage, James. 

1840. 

Sykes,  1821. 

Syme,  1832. 
do.  1835. 
do.     1842. 

do.     1859. 

do.     1860. 

do. 


Schiess,  G emus- 
sens,  1868. 


Sohort,  1857. 

Scarpa,  1828. 

Schrader,  1820. 


Arch.  Klin.  Chir., 
1S6S. 


Lancet,  Sept.  30,  1871, 


Norris  ;  Ehrmann 
(cit.). 


Ehrmann  des  effets. 


Norris  ;  Ehrmann. 


Brit.  Med.  Jr.,  1862,  p. 
489. 


Lancet,  18.53,  vol.  ii. 

p.  666  ;  1854,  vol.  i.  p. 

91. 

Med.  Time.s  &  Gaz., 

August,  1S56,  vol.  ix. 

p.  441. 

Arch.  Kliii.  Chir. 

(cit.). 


Med.  Chir.  Trans., 

vol.  xlviii.  p.  65. 

Lond.  Med.  Gaz.,  vol. 

xxviii.  p.  392. 

Korris  Contrib. ; 

Lond.  Med.  Gaz.,  vol. 

xxviii.  p.  392. 

do. 

Arch.  Klin.  Chir., 

1 868. 
Norris  ;  Ehrmann. 


Arch.  Klin.  Chir., 
1868. 
do. 

Brit.  Med.  &  Surg.  Jr. 

1848. 


Schmidt  Jahrb.,  No. 
146. 


Arch.  Klin.  Chir., 

1868. 

Norris  Contrib. 

Arch.  Klin.  Chir., 
1868. 


F. 


L. 


Eem.   parotid  tu- 
mor. 


Hem.  (after  open- 
ing  "  sanguine- 
ous tumor  of 
neck"). 

Hem.   w'nd   ext. 
carotid. 


Rem.  parotid. 


Aneurism,  traum. 


Wound   face    and 
temporal  region 
thrown  from  car- 
riage. 

Aneur.  carotid  (at 
bifurcation). 


Aneur.  ext.  carot 


Aneur.  vertebral 
(supposed  caro- 
tid). 


Aneur.   by  anast. 
head. 
Aneur.  int.  max.? 

Aneur.    carotid, 
traum. 

Hem.   ear   and 
mouth. 

Aneur.   carotid, 
traum. 

Aneur.   int.    caro- 
tid. 

Aneur.    carotid, 
traum. 

Aneur.    orbit, 
spont. 

Abscess    of   neck 
(supposed  an- 
eurism). 


Orbital   aneur. 
traum. 


Aneur.  ext.  caro- 
tid. 
Aneur.  carotid. 

do. 


12  y'rs 


A  few- 
min- 
utes. 

13  days 


3  w'ks. 


1  m'nth 


8  years 


3  years 


7  mos. 
5  mos. 

7  w'ks. 


1  year. 


8  years. 


May  9. 
1862.  ' 


3  years. 


THE    COMMON    CAROTID    ARTERY. 


87 


Common  Carotid  Artery — continued. 


Date  of 
operation. 


.a  ?; 


a>  o  OS 


Nov.  14, 
18r)3. 


April,  1S42. 


May  23, 

18ti2. 


Oct.  22, 
18.5.?. 

July  6, 
18)6. 


May  20, 

18')4. 
Oct.  28, 

1840. 
June  20, 

1821. 

Sept.  1832. 

Feb.  18, 

1 83.5. 

April,  1842 


June  17, 
isr)9. 
Julys, 
18ljn. 


None. 


Stli  day. 


11th  day 


Once. 


3d  day. 


■5th  day 


June  15, 

1S6S. 


Nov.  5, 
1857. 

M;iy  23, 
Ih-J.s. 

Nov.  14, 
1620. 


'^^ 


Once, 
fatally, 


Several 
times. 


Recovery. 


Condition. 


Recovered. 
Recovered 
Recovered 

Recovered 
Recovered 


Cured. 


Cured. 


Cured. 
Cured. 
Cured. 

Cured. 
Cnred. 


Recovered. 
Kecovered. 


Recovered. 

Recovered 
Recovered, 
Recovered. 


Cured. 
Cured. 


CauBo  of  death, 
dato  after  op. 


No  better. 

Cured. 

Cured. 

Not  cured. 


Next  day.    Exhaus- 
tiou. 


9th  or  10th  day. 


14th  day.     Cerebral 
complications. 


nth  day.  Complica- 
tion.s  and  hem. 


2Pth  day.  Hem.  ; 
cerebral  complica- 
tions. 

3d  day.     (  ? ) 


14th     day.     Hem. 
asphyxia. 


30  hours. 


The  internal  carotid  waH  torn  in 
two  ;  liffature  to  coinriioii  caro- 
tid incrcasi'd  the  hoili.,  and  liga^ 
turo  en  rnri.HHe  wa«  applied.  IJ 
year  later  patient  was  well,  al- 
I hough  Hie  tumor  wa8  not  en- 
tirely ri'moved  at  above  opera- 
tion. Internal  and  external  car- 
otids must  have  been  included 
in  the  ligature  "n  rnaSH' . 

Patient  had  lost  3  pints  of  blood. 


Hemiplegia,  3  hour.f  after  opera- 
tion, of  loft  side  of  body,  right 
side  face.  Autop.sy.  Softening 
of  right  anterior  lobe. 

8th  day  abundant  hemorrhage  ! 
12th  day  right  hemiplegia.  Au- 
topsy :  Left  hemisphere  soft- 
ened and  purulent ;  right  con- 
gested. 

Patient  lost  the  use  of  left  eye, 
and  hearing  of  same  side  im- 
paired. 

Patient  shaved  himself  on  7lh 
day  ;  paralysis  of  right  side  be- 
fore deatli  ;  uuconsciousne''8. 
Autopsy :  Carotid  closed  by 
thrombus. 

23d  day  suffocation,  sac  opened  ; 
26th  day  hem.  and  paralysis  of 
left  arm. 

After  ligature  partial  paralysis 
of  left  side. 

Afler  ligature  tumor  rapidly  in- 
creased :  burst  Hth  day  in  tra- 
chea. Autopsy :  Aneurism  wa.s 
between  trans,  proc.  4th  and  .5th 
cervical  vert. 

No  ansesthetic  ;  ulcerated,  and 
hemorrhage  before  operation. 

Sac  suppurated. 

2  lig.  of  catgut ;  artery  divided 
between  them. 


Syme   could  give  no  reason  for 
death. 


Died.      Hem. 


Method  of  Antyllus. 


The  tumor  was  found  to  be  a  cyst 
in  intimate  relation  with  the 
sheath  of  the  carotid.  Strange 
to  say,  it  diminished  notably 
in  size  after  operation. 

Patient  was  kicked  by  a  hor.se. 
Attempt  to  tie  the  remaining 
carotid  some  months  after  was 
abandoned  on  account  of  hemor- 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
opeiator. 


Source  of 
information. 


Cause  of 
operation. 


o  o 


Schuh,  184S. 


do.     1856. 


Schwartz,  1S44. 


do,         1850. 
Scott,  1S31. 


do.    1832. 

Smith,  J.  A., 

1865. 
Smith,  Prof. 
Stephen,  1876. 

do.  1857. 


Smyth,  A.  W., 

New  Orleans, 

1864. 


Spence,  IS 


do.     1842. 
do. 


Shipman,  1844. 

Staude,  1861. 
Stedman,  1830. 

Stevens,  1826. 

Stanley,  1859. 

Stromeyer. 

do. 

Szokalsky,1864. 


Arch.  Klin.  Chir. 
1868. 


do. 


do. 

do. 

Med.  Chir.  Trans.,  vol, 

xxii.  p.  134  ;  rep.  by 

Geo.  Busk. 


Norris  Contributions  : 

Ehrmann. 

Med.  Time,s  &  Gaz., 

April  8,  1835,  p.  358. 

N.  Y.  Med   Jr.,  June. 

1S76. 

N.  y.  Med.  Jr.,  July. 
1857. 

New  Orleans  Med. 

Press,  May,  1866  ; 

Guy's  Hosp.  Kep.,  vol. 

xvii. 

Schmidt  Jahrb.,  No. 
144,  p.  87. 


Norris  Contrib. 


Arch.  Klin.  Chir. 
ISdS. 


do. 


Am.  Jr.  Med.  Sci., 

July,  1847,  p.  264. 

do. 

Norris  Contrib. 

New  York  Med.  Phys. 

Jr.,  vol.  V.  p.  811. 

Arch.  Klin.  Chir. 

(cit.). 

do. 

do. 

do. 


M.     18 


M. 


Boy 


Shot  w'd  of  facial. 


Hem.  int.  max. 


Secondary  hem. 
(internal   maxil- 
lary) . 


Shot  wound. 

do. 
Hem.  from  nose  ; 
exophthalmos. 


Remov.   tumor 
face. 
Hem.  int.  carotid. 

Cancerous    tumor 
inf.  max. 


1  day. 


4  mos. 

5  days. 


To  arrest  malig. 
di-ease  left  sup. 
max. 

Aneur.    subcla- 
vian. 


Hein.  ulcerat. 
face. 

(Suicidal  stab  w'd 
carotid  at  bifur- 
cation.) 

Aneur.  carotid. 


Prep,   remov.  pa- 
rotid. 

Remov.  parotid. 
Parotid  tumor. 

Remov.  tumor. 

Hem.  after  punc- 
ture of  tonsil. 

Stab  wound. 


35  days. 


4  years. 

2  years. 
VI  y'rs. 


Shot  wound  max- 
illaris  interna. 

Aneur.   orbit, 
traum. 


5th  day 

before, 

and  day 

of  op. 


Above 
omo- 
hyoid. 


THE    COMMON     CAROTID    ARTEKY. 


89 


Common  Carotid  Artery — contimied. 


Date  of 
operation. 

-g  £  o 

a  sc 

RESULT. 

REMARKS. 

Keoovory. 

Condition, 

Cause  of  death, 
date  after  op. 

fi'>S 

Nov.  14, 
1848. 

Dec.  r), 
18.5U. 

July  26, 
1864. 

May  4, 

1840. 

ISC-O. 
Nov.  10, 

1834. 

Feb.  4  1832 

8th  day.    Cerebral 
complications. 

.3d  day  after  operation,  paralyslH 
of  leftside;  4th,  coma.  AiitopKy; 
Pleura  and  liingM  contfi^sted  ; 
riKht  hemisphere  softened. 

After  lit',  of  common  carotid  H 
inch  of'  the  jaw  was  resected, 
and  the  int.  maxillary  tied. 
Patient  died  3  months  later 
from  iiercosis  of  vertebral  col- 
umn and  tubercnlosis.  (The 
first  operation  was  made  to  ar- 
rest hemorrhnge  caused  by  tre- 
phining jaw  in  neurotomy  for 
facial  neuralgia.) 

Paralysis  of  right  side  day  after 
operation  with  aphasiii.  li  yr. 
after  operntion  all  unpleasant 
symptoms  had  disaiipeared  ex- 
cept difficulty  of  motion  in  right 
leg. 

No  cerebral  symptoms  of  note. 

No  cerebral  symptom*  of  note. 

Fell  through  a  ship's  hold  ;  38th 
day  after  accident  hem.  from 
nose  and  protrusion  of  eye  ; 
hem.  was  arrested  and  the  ex- 
isting exophthalmos  disappear- 
ed ;  loss  of  vision. 

fi?0 

30 

16 

28 

6'^n 

Recovered. 

Recovered. 

Eecovered. 
Recovered. 

Cured. 

Cured. 

Cured. 
Cured. 

fi'ii 

(i32 

633 

42  hours.     Convul- 
sious. 
In  a  few  hours.     ? 

634 

635 

Feb.  11, 
1 865. 

1870. 

April  24, 
18,57. 

May  15, 
1864. 

1869. 

May  24, 
1842. 

636 

14 
20 
13 

Recovered. 
Recovered. 
Recovered. 

Not  cured. 

Not  cured. 

Cured. 

Carbolized  catgut  lig.  Tumor 
continued  to  grow. 

637 
638 

6^t» 

4th  day.     Coma. 

61st  day.     Exhaus- 
tion. 
10th  day.     Pysemia. 

19th  day.     Hem. 

tied  at  same  operation.  ,54  days 
later  the  vertebral  was  tied. 
(Died  10  years  later  of  same 
aneurism.) 

640 

after    operation    paralysis    en- 
sued.    Autopsy:    The  "lig.  was 
found  to   have   slipped,  and  it 
was  thought  the  renewed  cur- 
rent had  washed   the   plug   in 
the  vessel  into  the  cerebral  cir- 
culation. 
No  cerebral  symptoms  noted. 

641 

642 

Julv  25, 
1865. 

May,  1844. 

12th 
after. 

ligatured  at  same  time. 

643 
644 

28 

Recovered. 

Recovered. 
Recovered. 

Recovered. 

Not  cured. 

? 
Cured. 

Cured. 

Disease  returned,  and  patient 
died  ia  2  years. 

645 

646 

Sept.  7, 
1830. 

June  3, 
1826. 

Oct.  24, 
1854. 

27thday 
hem. 

After. 

After 
op. 

26 
14 
14 

647 

61   days.     Cerebral 
complications. 

Died    instantly. 
Hem.;  exhaustion. 
Died.     Hem. 

time. 

Hemiplegia  on  31st  day  :  abscess 
and  softening  of  left  hemi- 
sphere. 

648 

640 

6,')0 

1864. 

C.u  i-pd 

No  cerebral  symptoms. 

90 


PRIZE     ESSAY. 


Surgical  Hiatory  of  the 


No. 

Name  of 
upera.tor. 

Source  of 
information. 

PATIENT. 

Cause  of 
operaiion. 

o 

o  i 

B 
Q 

c  o 
13 

1^ 

03 

01 
be 

n3 

"S  s 
fi  a 

J3 

fial 

Textor,  1826. 
Tilanus. 

Tyerman,  1834. 

Todd,  G.  R.  C, 

1876  (South 
Carolina). 

Von  Thaden, 

1864. 

do.  1836. 

Thebaud,  J.  S., 
186.5. 

Travers,  1815. 

do.       1826. 

do.      1809. 

Trier,  1834. 

Triboli,  ISto. 

Tschansofif, 

1867. 

do. 

do. 

T\vitcliell,1807. 

f    Unknown, 
J           1823. 
1        Ullman, 
L          1824. 
Unknown. 

do. 

(Crimea). 

Unknown,  1864. 

do. 

do.  1863. 

do.  1864. 

do.  1862. 
do.  1865. 

do.  1864. 

do. 

do.  1863. 

do. 
do.  1864. 

do.  1863. 

do. 

Ehrmann  des  effets, 
p.  38  ;  Arch.  Klin. 

Chir.,  1868. 

Velpeiiu  ;  Ehrmann 

des  effets  p.  38;   Arch. 

Klin.  Chir.,  1868. 

Norris  Contiib. 

Am.  Jr.  Med.  Sci., 
Jnly,  1877,  p.  112. 

Arch.  Klin.  Chir., 
1868. 
do. 

Letter  from  Dr.  J.  B. 

Reynolds,  with  Dr. 

Thebaud's  notes. 

Norris  Contrib.; 

Archives   etc. 

do. 

Med.  Chir.  Trans., 

vol.  ii.  p.  1. 

Arch.  Klin.  Chir., 

1868  (cit.). 

do 

Arch.  Klin.  Chir., 

Bd.  xi.  p.  203. 

Arch.  Klin.  Chir., 

p.  204. 

do. 

Norris  ;  Arch.  Klin. 
Chir.  (cit.). 

Arch.  Klin.  Chir. 

do. 

Norris  Contrib. 

Arch.  Klin.  Chir., 

1868. 

Med.  Surg.  Hist.  Reb.; 

Otis. 

do. 

do. 

do. 

do. 
do. 

do. 

do. 

do. 

do. 
do. 

do. 

do. 

M. 

40 

L. 

Knife  wound  ext. 
carotid. 

Aneur.  aorta  (sup- 
posed carotid). 

12  days. 

fi.i?, 

658 

M. 
M. 

M. 
F. 

M. 

M. 

F. 

M. 

M. 
F. 

M. 

35 
25 

22 

66 

6 
mos 

33 
34 

R. 
Ii. 

R. 
R. 

. . . . 

R. 
R. 
L. 

fin4 

Aneur. ;    pistol 
shot   wound  at 
bifurcation. 

Stab  wound. 

Of  w'd, 
17  days; 
of  au- 
eu-.,2-4 
4hours. 

Below 
omo- 
hyoid. 

6.-)n 

fi-ifi 

fii7 

of  nerve  (max. 
int.). 

Aneur.  anast.  face 
and  eye. 

Hem.  fung.  tumor 

of  cheek. 
Knife  wound  ext. 

carol. 
Erectile  tumor 

orbit. 
Knife  wound  sup. 

thy. 

Knife  wound. 
Epithel.   turn,  of 

parot. 
Epithel.   cancer 

lower  jaw   and 

mouth. 

firiS 

fial 

Short 
while. 

fifin 

fifil 

fifi? 

27 
50 

60 

R. 
R. 

fifi'^ 

5  years. 

RB4 

6fi5 

fifiR 

M. 

M. 

M. 

F. 
M. 

M. 

M. 

M. 

M. 

M. 
M. 

M. 

M. 
M. 

M. 
M. 

M. 

M. 

20 

19 
20 

R. 

L. 
R. 

Shot  wound  int. 

carotid  (neck  and 

face). 
Erectile  tumor  in 

region  of  left  ear. 
do. 

Aneur.;  face  w'd. 
Hem.;  shot  wound 

external  carotid. 
Shot  wound  lower 

jaw. 

do. 

do. 

Shot  wound  face. 

Shot  w'd  mouth. 
Shot  wound  lower 

ja,w. 
Shot   wound   face 

(right). 
Shot  wound  face. 

Shot  wound  inf. 
max. 

Shot  wound  sup. 
max. 
Shot  wound  face. 

Shot   wound  left 
mastoid  process. 

Shot  wound  inf. 
max. 

10  days. 

6fi7 

fifiS 

fifi<» 

6  w"ks. 

fi70 

671 

Mid 
asje. 
do. 

do. 

do. 

do. 
do. 

do. 

do. 

do. 

do. 
do. 

do. 

R. 
R. 
L. 

■rV 

R. 
L. 

R. 
L. 

67?, 

678 

674 

67  T 

676 

677 
67S 

(Near 
bifur.) 

June  19. 

July  1. 

679 

Above 
omo- 
hyoid. 

680 

681 

Below 
omo- 
hyoid. 
Above 
omo- 
hyoid. 

68'^, 

6S8 

Dec.  30, 
1862. 

THE    COMMON    CAROTID    AHTKIiY. 


91 


Common  Carotid  Artery — continued. 


])ato  of 
oporatiou. 

o  g  £ 

Recovery. 


May,  10, 
1S2(). 


OtU  day. 


Aug.  14, 
18:i4. 


Sept.  26, 
1864. 

Jan.  20, 
18t)6. 


Nov.  13, 

ISl.!. 

Jan.  27, 

1826. 
May  23, 

1809. 

1834. 

184,^. 
Oct.  1867. 


Oct.  18, 
1807. 

1S23. 

1824. 


20th  day 
and  aft. 


Twice. 


1864. 

July  8, 

1864. 
June  7, 

1863. 
June  19, 

1864. 

1862. 
April  11, 

1S65. 

i  July  4,'64 

L"     6,  " 

June  2.3, 

1864. 
July  18, 

1863. 

June  7, 

1863. 
May  16, 

1864. 

Oct.  10, 
1863. 


Condition. 


Cause  of  death, 
date  after  op. 


REMARKS. 


10 

1.5 

13 

11&22 


Recovered. 

Recoverod. 
Recovered. 

Recovered. 


Recovered. 


Recovered 


Recovered. 


Recovered. 
Recovered. 

Recovered 


30th  day.    Cerebral 
complications. 


Cured. 


Cured. 


Not  cured, 
hut  bene- 
fited. 


4J  days. 


16th    day.     Menin- 
gitis. 
56th  day.    Hera. 


Cured. 


? 
Cured. 


Recovered. 
Recovered. 


Recovered. 
Recovered, 


Cured. 


14th  day.    Tubercu- 
losis.    (?) 

8th  day. 

20th  day. 


3d  day.    Exhaust'n 

4   hours.     Exhaus- 
tion. 


2  days. 
Next  day. 

3  days. 

Died.  1st  op.  2  days. 
2d  op.  same  day. 
2  days. 

8  days. 

Same  day. 
Same  day. 

14  days. 

Died  Jan.  15,  1863. 


23d  day,  paralysis  of  ri^ht  side. 
Autopsy:  abhccss  in  left  hemi- 
sphere. 

Patient  died  suddenly  5  months 
later.  Autopsy:  Tho  an>Miiism 
of  aorta  was  full  of  solid  flbriii. 


'Comparatively  good    healtli." 
Tumor  long  since  disappeared. 


"Collapse  and  unconsoionsness 
day  alter  opovatioii.  Autopsy  : 
Both  hemispheres  congested." 


19th  day,  patient  was  wild  with 
delirium. 
Two  ligatures  applied. 

The  trachea  was  also  wounded. 


Autopsy:    No  thrombus  in  ^ea- 
tral  end,  in  distal  small  clot. 


Died  3  mos.  later  of  some  other 
disease. 


On  account  of  hem.  a  second  lig. 
had  to  be  applied  lower  down. 

Hem.  ceased  with  application  of 

ligature. 

■  Disability  J    and    permanent, 
April,  1867." 
This  artery  was   tied   a  second 
time. 


The  same  vessel  was  religatured 
on  July  6,  on  account  of  hem. 


92 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
opera4;or. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

"5 
g  6 

3 

Q 

o  2 
'a  '^ 
o  ^° 

t3 

«.-.  bo 

>< 

bo 

< 

6 
y 

a  O 

fi  a 

fiS4 

Unknown,  186-t. 

do. 

do.  1863. 

do.  1862. 
do.  1863. 

Med.  Suri?.  Hist.  Reb.; 
Otis. 

do. 

do. 

do. 

do. 

do. 

do. 

do. 
do. 

do. 
do. 

Arch.  Klin.  CMr., 

1868,  173. 

do.  174. 

do.  .'^06. 

do.  442. 

Madelung  ;  Arch. 

Klin.  Chir.,  Bd.  xvii. 

p.  616. 

Lancet,  1859,  vol.  i. 

p.  559. 

Med.  Surg.  Hist.  Reb.; 
Otis. 

N.  Y.  Med.  Jr.,  July, 

1857,  Prof.  Jas.  R. 

Wood. 

do. 

N.  y.  Hosp.  Notes, 

kindness  I'rof.  H.  B 

Sands. 

N.  Y.  Med.  Jr.,  July, 

1857,  Prof.  Jas.  R. 

Wood. 

do. 

Arch.  Klin.  Chir., 

1868. 

Med.  Sure.  Hist.  Reb.; 

Otis. 

Arch.  Klin.  Chir., 

18W. 
Norris  ;  Ehrmann  ; 
Arch.  Klin.  Chir., 

-  18^8. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 
M 

M. 
M. 

22 
21 

Mid 

age 

do. 
do. 
do. 
do. 
do. 

L. 
L. 

R. 

R. 
L. 

Shot  wound  lower 
jaw. 

Shot  wound  neck, 
internal  and  ex- 
ternal carotid. 

Shot  wound  neck, 
high  up. 

Shot  wnd  mouth 

and  neck. 
Shot  wound  neck 

and  face  (r.) 
Shot  wound  neck 

and  jaw. 

MavlO, 
1864. 

685 

6Sfi 

fiS7 

May  30. 
May  3. 
April  12 

fore  op. 

fiS8 

R89 

May  5. 

690 

(      do.  1862. 

\           do. 
do.  1864. 

R91 

do. 
Shot  wound  head 
aud  neck. 

. 

Sfti^ 

May  5. 

May  12 
to  21. 

fiP.S 

fi94 

do.  1864. 
do.  1S55  ? 

23 

R.     Shot,    ■wniinH    fi-an'. 

R9-) 

ture  of  riifht  pa- 
rietal   bone    cut- 
ting  middle  me- 
ningeal artery. 

fi9R 

M. 

35 

L." 

glands. 
Hem.  of  mouth. 

R97 

fi9S 

(supposed  caro- 
tid). 

Tumor   (carcino- 
ma)  of  temporal 
muscle;  supposd 
aneurism. 

Cirsoid    aneurism 
of  scalp. 

Hem.    of    mouth  ; 
fell  with   pipe- 
stem  in  mouth. 

Shot  wound  ;    r. 
mastoid  process. 

Malignantdisease 
of   right  nasal 
fossa. 

Cirsoid    aneurism 
of  scalp. 

Aneurism  of  orbit, 
left  traumatic. 

Hem.  of  external 
carotid  ;  removal 
of  parotid  tumor. 

Enceph.  tumor  of 
right  orbit. 

R99 

do.  Hotel  Dieu. 

Ure,  1859. 

Valk,  N.  N., 
18S4. 

W.  H.,  1849. 
do.  18.30. 

do.  1854. 

do.  1852. 
do.  1857. 

Vanzetti,  1865. 

Vansant,  J., 
1865. 

Vargus,  1823. 
Velpeau,  1835. 

M. 

jvi. 

M. 
F. 
F. 

M. 

P. 
M. 

M. 
M. 

F. 
M. 

20 
35 
21 
40 
17 

23 

L. 

R. 
R. 
L. 

L. 

7nn 

7  hours. 

Above 
omo- 
hyoid, 
do. 

701 
702 

Aug.  25. 

Sept.  7. 

703 

704 

70') 

70R 

25 

60 

Mid 
age. 

30 
16 

R. 

L. 

L. 
L. 

707 

708 

Shot    wound    left 
side  of  head. 

Aueur.  carotid. 

Feb.  6. 

Feb.  15. 

709 

713 

temporal  region. 

THE    COMMON    CAUOTTI)    ARTERY. 


P3 


Common  Garoiid  Arlery — continued. 


Date  of 
operation. 

E  !-  fc, 
o  c  ® 

age 

4>   O   C4 

X 

Sog' 

KESCI.T. 

RKMARKB. 

No. 

Condition 

Recovery. 

Cause  of  death, 
days  after  op. 

«S4 

June  2, 

1804. 

(   June  in, 

{       1864. 

(  Julys, '64 

Oct.  10, 

1863. 

June  18, 

1862. 

May  16, 

1863. 

Mays.     (?) 

(  May  17,'62 

May  21, 
lb64. 

Next  day. 

17  days  aftfr  Ist  op. 
2     "         "       last " 

Next  day. 

4  days. 

Died  May  1.1. 

Same  day. 

Same  day. 
Next  day. 

13  days.     Hem. 

Internal    jugular    vein     bcini; 

fiSi 

July  2. 

wounded  in  operation  wa8  aUo 
tied. 
Tlio   veHsel   vtslh   tied   a  Bccond 

68(5 
fiS7 

19 

Recovered. 

7 

time  on  account  of  hem.  1.3  days 
alter  Int  operation. 

Lingual  was  also  tied. 

fiS8 

Ball  entered  neck,  right  side,  tra- 

fiSO 

versed  antrum  and  out  at  no^e. 

(iqn 

mi 

603. 

Recovered 

Recovered. 
Recovered. 

Cured. 
Cured. 

694 

May  13, 
1864. 

After. 
.30  days. 

Details  not  given. 

Details  not  given. 

Paralysis  of  right  arm  resulted. 
Autopsy:  Aneurism  of  veriebral 
between  2d  and  3d  cervical  vert. 

fiflfi 

m7 

20th  day. 
Died.     (?) 

fits 

fiW 

Recovered. 
Recovered. 

Ijnproved. 
Cured.    ? 

Temporal,   auricular,   and  occi- 
pital tied  at  same  time. 

No   cerebral   symptoms;    symp- 
toms were  favorable  on  31st  ult. 

700 

May  21, 
lSo9. 

Sept.  9, 
1864. 

1849. 
1850. 

June  24, 

1854. 

1S52. 
1857. 

1865. 

Fel).  15,  '65. 
Kelig.  21. 

Aug.  18, 
18-23. 

1st  and 
2d  day, 
slight. 

701 

nth  day. 

60  hours.     Cerebral 
complications. 

70? 

Hemiplegia  in  24  hours.    Autop- 
sy :  Right  hemisphere  softened. 

Disease    latent ;     right    carotid 
had  been  tied  6years  previously 
ly  Dr.  J.  K.  Kodgers.     No  cere- 
bral symptoms  followed. 

7ns 

14 
15 

Recovered. 
Recovered. 

Recovered. 

Not  cured. 

Not  cured, 
but  iuipr'd 

Cured. 

704 

70i 

day.     IS  months   later   patient 
improved   and    condition  good. 
Pressure  on  right  carotid  slops 
pulsation  in  tumor. 
Superior  thyroid  also   tied 

Pain   ceased   on  tightening  lig. 
Autopsy  :  Healthy  clot  in  boTh 
central  and  distal  ends  ;   orbit 
and  zygomatic  fossa  filled  wiih 
canci-rous  matter. 

70fi 

13th  day.     Pyjemia. 

8th  day. 

^'^^l    4     •'•      hem. 

16th  day.     Hem. 

707 

70S 

Once. 

Hem.  recurring  same  vessel  was 

70<» 

Recovered. 

Cured. 

tied  6  days  after  1st  operation. 

710 

Often. 

94 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 
1=1  S 

u 

a 

t3 

S   =1 

,^  bo 

CO 

bo 

6 
-a 

*  2 

711 

Velpeau,  1S39. 

Verneuil,  1863. 
do.        1871. 

do.       1870. 
Vilardebo,  1847. 
Vincent,  1845. 
do.       1829. 
do.       1818. 
Voisin. 

■Wagstaffe,1872. 
Walton,  1851. 

Walt  her,  C, 

1830. 

Von  Walther, 

P. 

Watson,  J., 

'       18.53.  (?) 

Warren,  1 827. 

do        18S0. 
r     do.       1843. 

■i          do. 

do. 

do.       1837. 

do.       1836. 
do.       1827. 

Wardrop,  1818. 

do.        1826. 

do.        1827. 

do.        182.5. 

do.        1826. 
Wattman,  1823. 

Webster,  N., 

1864. 

Weber,  G.  0., 

1853. 

Norria  Contrib.; 
Arch.  Klin.  Chir., 

1868. 

Arch.  Klin.  Chir., 

1868. 

Gaz.  des  Hop.,  1871, 

p.  442;  Lancet,  Nov. 

4,  1871,  p.  644. 

Gaz.  Hebdom.,  Nov. 

10,  1876,  p.  709. 

Arch.  Klin.  Chir., 

1868. 

Norris  Contrib. 

Norris  Contrib.; 
EhrmauD  (cit.). 
Norris  Contrib. 

Eve  Collect.  Remark. 
Cases ;  Arch.  Klin. 

Chir.  (cit.). 

Lancet,  June,  1872. 

Med.  Times  &  Gaz., 

lS.i4,  vol.  i.  p.  185. 

Arch.  Klin.  Chir. 

(cir.). 

do. 

N.  Y.  Med.  Jr.,  July, 
1857. 

Norris  Contrib.  (cit.). 

do. 

Am.  Jr.  Med.  Sci., 

April,  1846. 

do. 

Norris  Contrib.,  etc. 

Arch.  Klin.  Chir., 

1868. 
do. 

Lancet,  vol.  xii.  p.  .394. 

Norris  Contrib. 
Lancet,  vol.  xii.  p.  762. 

Norris  Contrib. 

do. 

Ehrmann  des  effets  ; 

Arch.  Klin.  Chir. 

(cit.). 

Med.  Surg.  Hist.  Reb.; 

Otis. 

Arch.  Klin.  Chir., 

1868. 

M. 

M. 

M. 
M. 
M. 
M. 
M. 
M. 

F. 
M. 
M. 
F. 

M. 

F. 
M. 

M. 

M. 
F. 
M. 

F. 

M. 
F. 

m"." 

M. 
M. 

28 

41 
30 

32 

70 
28 
48 
52 

5 
mos 
29 

38 

Y'g 

42 

18 
23 

23 

52 
45 
60 

6 
WliS 

5 
mos 

22 

75 

57 
55 

Mid 

age. 

63 

R. 

E. 

R. 
E. 
R. 
R. 
R. 

R. 
L. 
L. 
L. 

L. 

R. 
L. 

R. 

R. 
L. 
L. 

L. 

L. 

L. 

R. 

R. 
E. 

R. 

An  eur.orb .  ,traum. 
(of  both  sides). 

6  mos. 

^^9. 

713 

tumor  of  parotid. 
Hem.  shot  wound 
of  cheek. 

Hem.   foUowiut; 
lii;-.  ext.  carotid. 

Aneurism  of  caro- 
tid and  innom. 

Hem.    wound   of 
tongue. 

Aneurism. 

do. 

St  lb    wound   ver- 
tebral. 

Aneur.  of  orbit. 

21  days. 

May  23. 

714 

15-30 
and 
after. 

71.') 

716 

8  days. 
8  mos. 
3  w'ks. 

717 

71 S 

719 

720 
7?,1 

3  mos. 

722 

723 

724 

carotid. 
Stab   wound   ver- 
tebral. 

Aneurism. 

Erect,  turn,  orbit. 
Erect. turn,  mouth, 
face,  neck. 

do. 

Scirrh.  tum.  neck. 

Remov.  tum.  thy- 
roid. 

Prep,   removal  of 
glands   of  neck 
for  malig.  dis. 

Erect,  tum.  cheek. 

Erect,  tum.  face. 

Erectile  turn,  face 

and  head. 
Carotid  aneurism, 

low  down, 
do. 

72o 

7m 

727 

7'>8 

729 

7M) 

30y'rs. 
2  years. 
1  year. 

6  w'ks. 

7'?1 

732 

73.S 

734 

73f) 

12  y'rs. 

73fi 

737 

738 

739 

gland. 

Shot  w'nd   (flesh) 
face. 

Hem.  after  opera- 
tion for  exlirp. 

Mays. 

740 

THE    COMMON    CAROTID    ARTERY 


05 


Common  Carotid  Artery — continued. 


No. 

Date  of 
operation. 

ni 

|s1 

COO 

KEBULT. 

RE.MARKS. 

Recovery. 

Condition. 

Cause  of  death, 
date  after  op. 

711 

July   1839. 

Recovered. 
Recovered. 

Improved. 
? 

PresHuro  of  right  carotid  arront- 

712 

20 

42  hours.    Coma. 

Next  day. 

21st  day. 

6th  day.     Hem. 

7th    day.     Cerebral 
complications. 

33d  day.   Inflamma- 
tion of  sac. 

Died. 

ed  pulsation  in  tumor  of  left 
orbit  comiiletcly  and  l<>HH'-ned 
jiulsation  In  tliat  of  ri^'ht  eye, 
and  vice  vfrita.  .\flor  operation 
tumor  of  left  side  ci-ased  to  pul- 
sate, and  sight  was  diminished. 
6  months  later  improved,  not 
cured. 

718 

July  2, 
187). 

Feb.  5   1870. 

Two  ligatures  to  carotid  ;  hemi- 
plegia immediate.  Autopsy: 
"  Right  hemisphere  prufonnri'ly 
altered."  (flute.— 'Ry: I.  and  int. 
carotid  also  tied  in  a  8ini,'le  loop 
of  ligature.) 

714 

715 

716 

April  16, 

1845. 
July  IS, 

1829. 
Dec.  19, 

1818. 

Once. 

717 

Autopsy:  Softening  of  right 
hemisphere. 

718 

22 

719 

720 
721 

June  5, 
1851. 
1830. 

23 
14 

Recovered. 
Recovered. 
Recovered. 

Cured. 
Cured. 
Cured. 

No  cerebral  symptoms. 

722 
7?8 

3d   day.      Cerebral 
symptoms. 

7-H 

2  days  after  operation  paralysis 
(rig'ht)  ;  internal  jugular  vein 
was  also  tied.  Autopsy :  Brain 
softened. 

725 

Oct.  26, 

1827. 

Jan.  2, 1830. 

Recovered. 

Recovered. 
Recovered. 

Recovered. 

Recovered. 
Recovered. 
Recovered. 

Cured. 

Cured. 
No  better. 

Improved. 

796 

727 

f     Oct.  5, 
1845. 

J     Nov.  9, 
1845. 

March  7, 

1837. 
Sept.  14, 

I'^SS. 

1827. 

1818. 

March,  1826 

Oct.  (?) 

1827. 

June,  1825. 

728 

half  after  1st  ligature,  but  there 
was  no  positive  improvement. 

729 
730 

by  removing  a  portion  and 
plunging  needles  into  the  re- 
maining parts.     Cured. 

7th  day  coma;  parn lysis  of  left 
arm.  which  disappeared. 

7S1 

? 

732 

Patient  died  1  year  later  from  re- 

73:^ 

14th  day.     Exhaus- 
tion. 

turn  of  disease. 
Tumor  ulcerated  freelv  after  op- 

734 

11 
25 

Recovered. 
Recovered. 
Recovered. 

Cured. 
Improved. 
Improved. 

eration. 

733 

Died  103  days  after  operation  ; 
psoas  abscess. 
(Distal.) 

\(Di.itnl.) 

736 

737 

23d  day. 

Died.     Brain   com- 
plications. 

S  days. 

[62d  day.     Hem. 

) 

738 

1825. 

June  22, 
1864. 

Nov.  11, 
1853. 

Day  after  operation  paralysis  of 
j  left  side. 

7.39 

740 

Twice. 

14 

1 

96 


PRIZE    ESSAY. 


Surgical  History  of  the 


No. 

Name  of 
operator. 

Source  of 
informatiou. 

PATIENT. 

Cause  of 
operation. 

o 
O  " 

:c  S3 

^    en 

3 

"o  o 
"n  «* 

13 

5:2 

0  '^ 

y. 

< 

^  s 

741 

f       Weber, 
G.C.E.,1857. 

do. 

Weeker,  1S6S. 

Weinlechner, 

1861. 

do.  1863. 

Weir,  R.  P., 

186;?. 

do.  1864. 

do. 
do.  186.3. 

do.  1862. 

do.  1863. 
do.  1876. 

Wickham,  1829. 

Williams,  1825. 

Williaume, 
182  >. 

Wood,  Prof. 
J.  R.,  1839. 

do.     1840. 

do.     1842. 
do.     1843. 
r     do.     1855. 
j           do. 

do.     1847. 
do.     1S54. 

do. 

Wciodward, 
A.  T.,  1860. 

Am.  Jr.  Med.  Sci., 
April,  1860,  p.  574. 

do. 

Schmidt  Jahrb.,  No. 

144,  p.  200. 

Arch.  Klin.  Chir., 

IStiS. 

do. 

Med.  Surg.  Hist.  Reb.; 
Oiis. 
do. 

do. 
do. 

do. 

do. 
Letter  to  author. 

Norris  Contrib. 

Arch.  Klin.  Chir., 

1868. 

Norris  Contrib.: 

Arch.  Klin.  Chir., 

1S68. 

N.  Y.  Med.  Jr.,  July, 

1857,  Prof.  Jas.  R. 

Wood. 

do. 

do. 
do. 
do. 
do. 
do. 
do. 

do. 
Letter  to  author. 

M. 

M. 
P. 
P. 
P. 
M. 
M. 

M. 
M. 

M. 
M. 

20 

20 

63 

40 

41 
y>rs 
Mid 
age 
do. 

do. 
do. 

do. 
25 

L. 

R. 
L. 
R. 
R. 
R. 
L. 

R. 
L. 

R. 

R. 
R. 

Epilepsy. 

do. 

Pulsating   tumor 

of  left  eye. 
Secondary  hem. 

(facial). 
Hemorrhage. 

Shot  wound  right 

sup.  max. 
Shot    wound   inf. 

max.    (lingual, 

verteiiral,   and 

oesophagus). 
Shot   wound  inf. 

max. 

Shot   wound   left 
side  of  neck. 

Shot  w'nd  spinal 
cord   and   neck 
(aneurii-m). 

Shot  wound  face. 

5  years. 

742 

743 

Several 

months. 

Short 

time. 

15  days. 

744 

74.'-. 

746 

Sept.  17 
Aug.  25 

July  9. 
Jan.  1. 

About 
Sept.  24. 

July  3. 

Sept.  25. 
Sept.  3. 

July  19. 
Jan.  1 

747 

748 
749 

Below 
omo- 
hyoid. 

750 
7o1 

Below 
omo- 
hyoid. 

and 
after. 

July  9. 

7o2 

7o.S 

M. 

M. 
M. 

P. 

P. 

M. 
M. 
M. 
M. 
M. 
M. 

M. 
P. 

55 

Aneurism  innom. 

7o4 

7/)fi 

21 

Mid 

age 

36 

6 
mos 
37 

53 

53 

36 

.23 

Mid 
age 
do. 

L. 

L. 

R. 

R. 
R. 
R. 
L. 
R. 
L. 

L. 

L. 

7fifi 

Suicide ;   knife 
wound  of  throat. 

Aneur.  carotid  at 
bifurcation   of 
innominate. 

Aneur.   auast.   of 
cheek. 

Epilepsy. 

Malig.  disease  of 
antrum, 
do. 

Aneurism  of  ext. 

carotid . 
Malig.  disease  of 

antrum. 

Malignant    tumor 

of  left  jaw. 
Aneur.  anast.   of 

left  ext.  carotid. 

757 

6  mos. 

Above 
omo- 
hyoid, 
do. 

75S 

759 

7fin 

Some 
time. 

Above 

omo-hy. 

do. 

do. 

do. 

Below 
omo-hy. 

7fi1 

7fi^ 

7fi3 

7fi4 

765 

THE    COMMON    CAROTID    ARTERY. 


97 


Common  Carotid  Artery — continued. 


No. 

Date  of 
operation. 

U    ^    '_. 

o  0  a> 

e  be 

W 

1^1 

t3 

RESOLT. 

REMARKS. 

Kecovery. 

Condition. 

Cause  of  death, 
date  after  op. 

741 

r    Dec.  2, 
1857. 

- 

Dec.  19, 

1857. 
Juno  20, 

1868. 
May  19, 

1861. 

12 

Recovered. 
Recovered. 

Interval  of  17  days  between  the 
2  oporatioriH  ;  6  woekg  after  laft 
operation  no  attack,  but  mind 
weaker. 

Paralysis  of  right  side  followed 
operation. 

742 
743 

Improved. 

52  hours. 
6  days. 

744 

745 

8-9 

Recovered. 
Recovered. 

Cured. 
(?) 

No  cerebral  symptoms. 

746 

Nov.  14, 

1863. 
Sept.  3, 

1864. 

July  20, 
1864. 

Feb.  26, 
1863. 

Sept.  .30, 
1S62. 

July  10, 
1863. 
1876. 

Sept.  26, 
1829. 

Next  day.    Hem. 
32d  day. 

747 

Once. 

38,41 
days. 

748 

On  account  of  hemorrhage   the 
artery  was  religatured  on  Aug. 
30th. 

749 

750 

2  days. 

None. 
Once. 

3d  day.     Hem. 

3d  day. 

11th  day.     Hem.  ; 
asphyxia. 

a   little   below   thyroid    notch, 
passing  out  left  of  occipital  pro- 
tuberance. 

751 

7.'J2 

Antiseptic  ligature  ;  no  cerebral 
symptoms  ;   subclavian  tied   at 
the  sume  time.     Autopsy:    Sac 
bursted  in  trachea.     (Distal.) 

753 

Recovered. 

Recovered. 
Recovered. 

Temporary 
improvem't. 

(?) 
Improved. 

754 

33d  day.     Hem. 

rupture  of  the  sac.    Subclavian 
was  tied  on  3d  December. 

755 

756 

June  26, 

1829. 

June  26, 
1839. 

Dec.  13, 

1840. 

March  2, 

1842. 

Sept.  2, 

1843. 

f    July  2, 

J        1856. 

1    Sept.  26, 

L       1856. 

■    Dec.  6, 

1847. 

Dec.  7, 

1854. 

Several 
times. 

21 

12 

12 

9 

15 
14 

"  Hem.  caused  by  patient  tear- 
ing wound  open  with  her  own 
hands." 

Patient  complained  of  queer  feel- 
ing in  head,  which  passed  off  in 
an  hour.     {Distal.) 

3  years  after  operation  bat  little 
change  in  tumor. 

No  cerebral  symptoms. 

757 

Recovered. 

Recovered. 
Recovered 
Recovered. 

Cured. 

Not  cured. 

Marked  im- 
provement, 
do. 

758 

759 
760 
761 

38th  day.     Exhaus- 

762 

13 

13 

Recovered. 
Recovered. 

Cured. 

tiou. 

763 

common  carotid  was  also  tied. 

764 

4th  day. 
4th  day. 

sloughed  after  operation  and 
brought  away  by  a  ligature  ;  6 
months  after  operation  patient 
fell  into  hands  of  a  quack  and 
died. 

Paralysis  on  opposite  side  a  few 
hours  after  operation. 

Dr   A   T  Woodward  kindlv  sent 

765 

me  another  case  where  he  tied 
the   right   common   carotid   foi" 
shot  wound  of  face  and  neck. 
Patient  was  living  several  days 
after  operation,  but  as  the  Dr. 
lost  sight  of  him.  and  the  result 
is  uncertain,   I    have    thought 
best  to  omit  this  case. 
1 

98 


PRIZE    ESSAY. 


Surgical  History  of  the 


Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

O 

o  o 

•3.2> 

t3 

ft. 9 

6 

be 

< 

6 

•2  u 

cS  o 

p  a 

J3 

Vfifi 

Woodward. 
G.  F.,  1857. 

Wynkoop,  G.H. 
"Wutzer,  1847. 
White,  1861-5. 

WMto,  1846. 

Wright,  W., 
1855. 

Zeiss. 

Z6rnroth,  L.H. 

N.  Y.  Med.  Jr.,  July, 

1857,  Prof.  Jas.  R. 

Wood. 

Notes  of  case,  courtesy 

of  Prof.  Willard 

Parker. 

Arch.  Klin.  Chir., 

1868  (cit.). 

Letter,  Dr.  J.  H. 
Erskine  (Med.  Direc- 
tor Army  of  Tennes- 
see). 
Lancet,  1846,  vol.  i.  p. 

149. 

Lancet,  1856,  vol.  i.  p. 

711. 

Norris  Contrib. 

Arch.  Klin.  Chir., 
1868. 

M. 
M. 

M. 

33 

li 
y'r. 

25 

R. 

R. 

R. 
R. 

L. 
R. 

Cancerous   tumor 
orhit  and  brain. 

7fi7 

7fi8 

face  (ulcerating). 

7fiP 

carotid. 

77n 

M. 
M. 

34 

70 

15 
mos 

Anenrism,carotid, 
near  bifurcation. 
Aneurism,  innom. 

Erect,  tum.  face. 

Aneurism    tempo- 
ral artery  (arte- 
riotomy). 

3  mos. 

771 

77"^ 

77-? 

Appendix  to  History  of  the 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

3  " 

-  9 

P-l    <o 

■a 

(4-t      • 

c  >> 

-2  3 
=1.9 

0) 

< 

6 
•p 
m 

ft  i 

774 

Guthrie. 

Eve,  Prof.  Paul 

F.  (Nashville, 

Tenn.). 

do. 

Cooper,  B.  (See 

122-3). 
Hodges,  1S6S. 

Hobart,  1839. 

Nash.  Jr.  Med.  Surg., 
Feb.  1874. 

Letter  to  author. 

do. 

Boat.  Med.  Surg.  Jr., 
Aug.  6,  1868. 

Guy's  Hosp.  Rep., 
vol.  xvii. 

F. 

53 

775 

of  neck. 

776 

777 
778 

M. 
F. 

35 

25 

R. 
R. 

Innominate  aneu- 
rism. 

Aortic  aneurism 
(supposed  in- 
nominate). 

779 

THE    COMMON    CAROTID    ARTERY, 


99 


Common  Carotid  Artery — continued. 


Date  of 
operation. 

o  [3  5 

o:"  o  rt 

■a 

BBStTLT. 

KEMARKS. 

Recovery. 

Condition. 

Cause  of  death, 
date  after  op. 

766 

April  18, 
1857. 

Nov  1   1868 

Eopeat- 
edly. 

1 
50th  day.     DiseaHe,'Paralv«lH  reHulted  on   loft  Hide- 

767 

21 

18 

Recovered. 
Recovered. 

Cured. 
Cured. 

hem.,  and  cerebral 
coraplicationij. 

42d  day.    Tumor   continued  to 

grow. 

768 
769 

both  endH  bein«  cut  off  and  left 
in  vround  ;  the  loop  worked  out 
on  'Mat  day. 

3  days.    1 

88th  day. 

114  days.     Cerebral 
complications. 

going  Into  tumor,  it  was  deemed 
irniiracticalile  to  tie  the  ext. 
carotid. 

770 
771 

Aug.  28, 

184.^. 

Oct.  1,  1855. 

6,  10,  11 
days. 

10 

Recovered. 

Cured. 

Paralysis  (left)  followed  opera- 
tion ;  absc(^ss  of  brain  at  autop- 
sy.   Distal. 

772 

8 

77S 

Once. 

Recovered. 

Cured. 

Common  Carotid  Artery. 


No. 

Bate  of 
operation. 

CD 

If? 

f-l       2       P-l 

O   S   OJ 

o     ■   P< 

RESULT. 

REMARKS. 

Recovery. 

Condition. 

Cause  of  death, 
date  after  op. 

774 

Recovered. 

Not  cured. 

775 

was   tied,   but    did    not    arrest 
hem.    The   external  was   then 
secured  above  the  wound,  and 
this   did  not  arrest  hem.     The 
internal  carotid  was   nest  se- 
cured, and  hemorrhage  ceased. 
The  disease  returned,  and   pa- 
tient died  6  months  later. 
(For    Dr.    Eve's    3d    case     see 
Mott,  V.) 

776 

Recovered. 

11th  day.     Exhaus- 
tion and  hem. 

ISth  day.     Hem. 

777 

778 

April  11, 
1868. 

1839. 

sth  day. 

16th 
day. 

Distal.  The  subclavian  wa*  tied 

779 

in  its  3d  division  at  pame  time. 
Sth  day,  internal  jugular  vein 
burst  and  was  tied. 

in   1st  division   at  same   time. 
Patient  did  well  until  16th  day, 
when   in   a   fit   of    passion    she 
sprang  from  her  bed  and  threw 
a  pillow  and  some  books  at  the 
attendant.     Hem.  from  carotid 
ensued,  and   death.     Autopsy: 
Subclavian      closed,      carotid 
open,  although   the   aorta  and 
not  the  innominate  was  the  seat 
of  the  disease,  the  pulsation  in 
the   tumor    had   ceased   before 
death,  and  the  process  of  cure 
had  begun. 

100 


PRIZE    ESSAY. 


Appendix  to  History  of  the 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


780      Parker,  Prof. 
Willard,  1863. 


781 

782 


786 
787 


Bickersteth, 
1864. 

Little,  Prof. 
Jas.  L. 


Speir.  S.  Fleet, 
Bruotlyn,  N.  Y. 


Harwell,  Rich- 
ard, 1877. 

Paul,  .lolin, 

1830. 

Stimson,  D.  L. 

Cooper,  S.  E. 


Bradley,  E., 

New  Yor.t  City. 

1877. 


Notes  of  case  to 
author  from  Dr.  Par- 
ker. 


Mr.  T.  Holmes  in 

Lancet  for  1872. 

do. 


Notes  from  Dr.  Little. 


Notes  from  Dr.  Speir 

in  Birmingham's 

Archives  of  Clinical 

Surgery. 


Lancet,  Nov.  17,  1877; 

Am.  Jr.  Med.  Scl., 

Jan.  1878,  p   275. 

Lond.  Med.  Gaz.,  1838, 

vol.  viii.  p.  71. 
Dr.  Stimson  to  author. 

Amer.  Med.  Times, 
June  24,  1862. 

Notes  of  case  from 
Dr.  Bradley  to  author. 


M.  I  32 

I 


Subclavian  aneu- 
rism. 


Innominate  aneu- 
rism. 

Aneur.  aorta  and 
innominate. 


do. 


Aortic  aneurism 
( supposed  innom- 
in  ate). 


Aneurism  aorta, 
carotid,  subclav. , 
and  innominate. 

Pulsating  tumor 
ove  ear. 

Aneurism  of  com- 
mon carotid. 

Tumor  of  parotid 
and  submaxil'ry 
glands. 

Hem.  during  re- 
moval of  vascu- 
lar tumor  of  pa- 
rotid and  sub- 
maxillary region 
(Angioma). 


19i 
years. 


Near 
clavicle 


1  Mr.  Richard  Barwell.  Am.  Jr.  Med.  Sci.,  Oct.  1S7S,  p.  570,  and  January,  1878,  p.  27.5.  M. ;  45;  R. 
Aneurism  of  aorta,  innominate,  subclavian,  and  carotid  arteries.  Carotid  tied  Aug.  14,  1H77,  and  subclavian 
a  few  minutes  later  in  3d  division.  Tximor  diminished  rapidly  in  size  and  consolidated.  Nov.  14  patient  left 
the  hospital.  ''  On  the  22d  November,  he  walked  two  miles  through  snow  and  sleet,  thinly  clad,  sat  four 
hours  in  wet  clothes,  without  a  fire,  and  died  Nov.  24,  1877."  Autopsy  :  "  Bronchitis,  redema,  and  hypostatic 
pneumonia.  Muco-pus  in  large  and  small  bronchi.  Arterial  blood  was  dark.  The  innominate,  right  carotid, 
and  subclavian  were  obliterated.  No  vessel  opened  out  of  the  aneurism,  which  was  much  diminished  in  size 
and  consolidated." 

fit  is  probable  this  patient  would  have  lived  comfortably  for  a  much  longer  time  if  he  had  acted  more 
prudently.    The  reader  is  referred  to  the  summaries  for  results  of  these  double  distal  ligatures. — Author.'] 


THE    COMMON    CAROTID    A  H  T  E  K  Y . 


101 


Common  Carotid  Artery — continued. 


No. 


Dato  of 
oporalion. 


Sept.  2, 1863 


7S1 
7o2 


786 
787 

78S 


10,21,35, 
and  42 
days. 

None. 


18C4.    f 
1875.' 


Auff.  6, 
1B74. 


Aug.  14, 
1677. 

July  29, 
1S30. 
1877. 


Dec.  6,1877, 


U    !-'    O 
o  3   S 

a  vC 

QJ  O  ci 


P< 

a 

/I 

o 

^ 

t-. 

bn 

\f 

>. 

1-1 

rt 

OS 

t3 

Eocovory 


26,27,28, 
30,31, 3i 
days. 


3d 
week. 


Recovered. 
Recovered 


Recovered. 


Recovered 


Condition. 


Ciiuse  of  death, 
date  Hl'ter  op. 


42d  day.    Hem. 


0th  day. 

10  weeks, 
tion. 


Marked  im- 

provciiifnt 

to  date. 


Shock. 
Suffoca- 


34th   diiy.      Hem.  ; 
dyspnoea. 


Much  inip'd 

on  JNov.  13, 

1877. 

Cured. 


Cured. 


Several   weeks. 
CEdema  of  glottis. 


REMARKS. 


Wardrop.  Tho  Bubclavian  in 
iHt  divJBion  and  v^rtel'ral  w<t« 
tied  sarno  time.  Autopsy  hIiow- 
ed  tiiat  fatal  iieinorrlia);*!  wan 
from  divtdl  end  of  Biibciaviau. 

Distnl.  Subclavian  in  ,'jd  divi- 
sion tied  same  time. 

Wardrop.  -7  woks  later  sub- 
clavian  was  tied  in  3d  division, 
and  doaih  rnsulti^d  in  21  days. 

Dinlfil.  Subclaviau  was  tied  in 
3d  divi'^ion  sarne  time.  This 
case  will  most  likely  result  in 
a  cure. 

Dixtal.  Carotid  obliterated  by 
Dr.  Spier's  "  artery  coustric- 
ti'r,"  and  two  days  alter  this 
subclavian  was  tii'd  in  3d  divi- 
sion. (For  other  iuterestini; 
facts,  see  article  on  the  siibcla 
viau. — Aiithor.) 

Dintal.  Subclavian  tied  same 
time  in  3d  division. 


Turaor  was  removed  after  liga- 
ture. 

Tumor  grew  rapidly  within  the 
lasi  year.  In  operation  for  re- 
moval, while  dissectii]g  with 
the  handle  of  the  scalpel,  the 
tumor  gave  way,  and  a  fright- 
ful hemorrhage  occurred.  The 
common  carotid  was  tied  imme- 
diately above  the  clavicle,  the 
incision  being  made  behind  the 
posterior  border  of  the  mastoid 
muscle.  Heui.  ceased  instantly. 
The  recovery  was  prompt,  and 
the  tumor  has  entirely  disap- 
peared. After  ligature  of  the 
common  trunk  the  tumor  was 
not  removed,  but  the  wound 
was  packed  with  lint  soaked  in 
Monsel's  solution.  No  symp- 
toms of  cerebral  disturbance. 


102  PRIZE    ESSAY. 


The  following  cases  of  ligature  of  the  common  carotid  artery  were  discovered  after 
this  essay  was  finished.     They  are  not  considered  in  the  summary: — 

1.  Probably  by  Dr.  Jas.  R.Wood.  Bellevue  Hospital  Records.  M. ;  50  years. 
Cancer  lower  jaw.   Operation,  January,  1878.   Died,  from  exhaustion,  March  29,  1878. 

2.  Dr.  F.  p.  Porcher.  Am.  Jr.  Med.  ScL,  Oct.  1878,  p.  449.  M.;  38;  L.  An- 
eurism common  carotid.  Operation,  June  27,  1878.  Died,  hemorrhage,  July  4,  1878. 
Autopsy:  Sac  had  burst,  causing  death  ;  artery  was  tied  from  ^  to  f  inch  from  arch 
of  aorta ;  a  catgut  ligature  was  used,  which  had  become  loose,  and  the  artery  was 
not  occluded  !    "  No  clot  in  any  portion  of  it." 

3.  Dr.  Erskine  Mason.  Personally  to  author.  Boy.  Incised  wound  of  throat. 
Died  in  a  few  hours  from  exhaustion  from  hemorrhage  before  operation. 

4.  Same.  Personally  to  author.  M. ;  12  ;  L.  Lacerated  wound  under  jaw.  An- 
eurism resulted  July  10,  1861.  Dr.  Jas.  R.  Wood  tied  common  carotid.  Aneurism 
increased  in  size,  and  profuse  hemorrhage  occurred  July  16,  when  Dr.  Mason  opened 
sac  and  tied  the  artery  above  and  below  it.  Patient  died  in  15  minutes,  from  hemor- 
rhage during  operation. 

5.  Dr.  Geo.  E.  Post,  of  Beirut,  Syria.  F. ;  7;  R.  Supposed  recurring  fibroid 
tumor  of  neck.  In  second  operation  for  removal,  portions  of  the  internal  jugidar 
vein,  common  carotid  artery,  pneumogastric,  descendens  noni,  recurrent  laryngeal, 
and  sympathetic  nerves  were  excised.  The  wound  healed  kindly,  and  patient  was  dis- 
charged at  end  of  three  weeks.  The  only  important  symptom  after  the  operation  was 
paralysis  of  the  bladder,  which  disappeared  in  a  few  days.  The  child  died  four  months 
later  of  the  disease,  which  returned,  and  proved  to  be  encephaloid. 

[It  is  strange  no  general  disturbance  followed  section  of  the  sympathetic.  In  one 
of  the  fatal  cases  in  the  Surgical  History  of  the  Common  Carotid,  this  nerve  was  in- 
cluded in  the  ligature. — Author.^ 

Note. — Of  these  5  cases,  4  died  within  a  few  days,  and  the  other  within  a  few 
months  of  the  operation.  They  are  not  considered  in  the  summaries.  Nos.  729,  720, 
and  605  are  (by  errors  I  cannot  now  correct)  incomplete,  but  in  such  a  large  number 
of  cases,  these  few  mistakes  will  not  change  the  general  result. — Author. 


SURGICAL  HISTORY 


INTERNAL  AND  EXTERNAL  CAROTID  ARTERIES. 


104 


PRIZE    ESSAY. 


Ligature  of  the 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


Pg 


Buck,  Gurdon, 
1848. 


Burchard,  T.H., 

New  York,  1873, 


Byrd,  W.  A. 

(111.),  1876. 

Briggs,  W.  T., 
Nashville,  1871 


Brarablett, 
W.  H.,  1861. 


Hunt,  1862. 
Keith. 

Guthrie. 

McClellan. 

Parker,  Prof. 
Willard,  1855. 

Pancoast,  Prof. 


Sands,  Prof. 
H.  B.,  1872. 


Santesson,  1853, 


Smith,  Prof. 
Stephen,  1864. 


Velpeau,  1835. 
Verneuil,  1871. 


M.  Y.  Med.  Jr.,  July, 

1857,  Prof.  Jas.  K. 

Wood. 


do. 
Letter  to  author. 


N.  Y.  Med.  Jr.,  Aug. 
1876. 

Nash.  Jr.  Med.  Surs?.. 
Feb.  1874,  Prof.  Bowl- 
ing ;  Letter  to  author, 

N.  Y.  Med.  Record, 
Juue,  1869. 


Letter  from  Prof. 

Alfred  C.  Post  to 

author. 

Nash.  Jr.  Med.  Surg., 

Feb.  1874,  Prof.  Bowl 

ing. 

do. 


McClellan,  System  of 

Surgery. 

Note  of  case  from 

Prof.  P^i'ker. 

Dr.  S.  W.  Gross  in 
Am.  Jr.  Med.  Sci., 

April,  1867. 

Notes  of  case  from 

Prof.  Sands  to  author. 


Arch.  Klin.  Chir., 
1888  ;  Dr.  C.  Pilz. 


N.  T.  Jr.  Med.,  Jan. 

1874. 


Norris  Oontrib. 

Lancet,  Nov.  4,  1871, 
p.  644. 


Mid 
age 


Lacerated  wound  5  days 
anule    right   inf. 
max.  (glass). 


F. 


L. 


Wound  external 

carotid  of  its 

branches. 
Hem.  pistol  w'nd 

neck,   high   up 

(suicidal). 

Hem.  shot  wound 
near   angle  inf. 
maxilla. 

Aneur.  stab  w'nd 
internal  carotid. 


Hem.  shot  wound 
cheek. 


Knife  wonnd  int. 
carot.  (suicidal). 


Shot  wound  neck, 
high  up. 

Wound,  internal 
carot.  in  attempt 
to   remove   pin 
from  pharynx. 

Hem   wound  ext 
carotid  ;  removal 
of   tumor  from 
neck. 


Hem.  wound  ext 
carotid. 


Several 
weeks. 


July  4. 


^  inch 
above 
bif.  of 
com. 


High 
up. 


10th  d'y 

after 
wound. 


Secondary  hem. 
remov.  inf.  max, 
(malig.    tumor 
of). 


Removal  parotid 
tumor. 


Hem.  cancer,  dis- 
ease of  face. 


Erectile  tumor  of 

temporal  region. 

Shot  w'nd  cheek. 


21  days. 


Just 
above 
bifur. 


May  23. 


June 
15-80, 
e;c. 


THE    INTERNAL    CAROTID    ARTERY. 


105 


l7iternal  Carotid  Artery. 


No. 


Date  of 
oporatiou. 


1    July  9,1848. 


May  10, 
18')2. 

Sept.  1S73. 


May,  1876. 


Feb.  23, 
1871. 


^  9 


Hi  n  cs 


Jan.  3, 
1855. 


1835. 

July  2, 

1871. 


llecovory. 


CauHe  of  death, 
date  after  op. 


RKMAKKB. 


Recovered. 


Recovered. 


Cured. 


Cured. 


Cured. 


Hem.  occurred  7]Ht  day  iiftcr  op- 
eration, 2  ouiic<;h  ;  Htupjiod  «pon- 
taneouHly  ;  common  caroiid  tk-d 
Kame  ojioraiion.  Facial  paral- 
ysis pcrKiKtont  and  complotc 
(caiiHod  doubtloHH  by  injury  to 
facial  norve  by  j^liiHH). 
nth  day.     Pyajinia.  Commou  carotid  waH  also  tied. 


20minute8.  Exhaus- 
tion ;  hem. 


Recovered 


Recovered. 
Recovered. 

Recovered, 

Recovered. 


Recovered 


Not  cured. 


2  days. 


Next  day.    Exhaus 
tion  ;  shocK. 


Cured. 


Cured. 


leth  day.     Hem. 
42  hours.     Coma. 


Ext.  carotid  tied  same  time. 


Hem.  had  benn  immonse  before 
Dr.  B.  could  arrive.  E.>ct.  and 
common  carotid  also  tied. 

Common  carotid  wan  first  tied  ; 
hem.  not  arrested  ;  IJr.  B.  cut 
into  sac  and  tied  b'lth  ends  of 
wounded  internal  caroiid. 

Hera,  not  ceasing  with  lig.  of 
internal  carotid,  Iho  common 
and  ext.  carotids  were  also  tied. 

Common  carotid  first  tied  but  did 
not  arrest  hem.  ;  internal  next 
tied,  still  no  arre>t  oT  bleeding  ; 
external  carotid  ti<^d,  hem.  stop- 
ped. Int.  jug.  vein  was  also  tied. 

Common  carotid  was  also  tied. 


Only  one  ligature,  and  that  on 
proximal  side  of  wound.  Hem. 
was  coiitroUcd  by  pressure  on 
cjm.  car.  until  the  int.  was  tied. 

Common  carotid  tied,  no  arrest 
of  hem.  ;  external  then  tied  on 
distal  side  of  wound  :  hem.  still 
continued,  and  did  not  cease  un- 
til internal  carotid  was  .-secured. 
Patient  died  6  months  later  from 
return  of  disease. 

Ext.  carotid  was  tied  same  time. 

The  common  carotid  was  first 
tied,  but  hem.  was  not  arrested 
until  ligature  of  inter'l  carotid. 

The  internal  jugular  vein  was 
tied  at  the  same  time.  There 
was  no  cerebral  disturbance. 

In  operation  for  removal  of  tu- 
mor internal  jugular  vein  was 
wounded  and  tied  wiih  lateral 
ligature;  10  days  later  hem. 
from  ulceration  of  internal 
ciratid,  which  was  tied  above 
and  below  bleeding  point,  ard 
common  car  ot  I  '<  tied  just  below 
bifurcation.  The  extornal  car- 
otid was  secured  at  the  first  op. 

The  internal  carotid  was  torn 
in  two  during  operation  ;  c  •m- 
mon  carotid  tied,  increasing 
hemorrhage  ;  the  vessels  were 
ligatured  then  e.n  mouse. 

External  carotid  also  tied  ;  no 
cerebral  symptoms.  Disease 
returned  and  patient  died  some 
months  after. 

Common  carotid  also  tied. 

[Common  carotid  also  tied;  ext. 
.  and  internal  in  single  ligatuie; 
\  hemipTa  immediate.  Autop>y: 
I  Lea  hemis.  profoundly  altered. 


106 


PRIZE    ESSAY. 


Ligature  of  the 


No. 

Name  of 
oiierator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

a  6 
.2  " 

11 

3 

^  a 
o  o 

(It's 

13 

-2  '5 

9 

oil 

CO 

< 

1 

Bertherand, 
1860. 

Ehrmann  des  effets. 
Dr.  Madeluns  ;  Arch. 
Klin.  Chir.,  vol.  xvii. 

F. 

4^ 
mos 

L. 

Erectile  tumor  of 
temporal  region. 

2 

Boeckel,  1861. 

Arch.  Klin.  Chir., 

1868;  Gaz.  Med.  de 

Strasbourg,  1862,  No. 

6,  p.  100. 

F. 

50 

E. 

al  enchondroma 
near  angle  jaw. 

3 

Burchard,  T.H., 

1873. 

Letter  to  author. 

M. 

60 

L. 

Hem.  pistol  w'nd 
neck,   high   up 
(suicidal). 

^  inch 
above 
bif.  of 
com. 

4 

'    Busch,  W., 

1872. 

Schmidt  Jahrb.,  Bd. 
167,  p.  66  ;  Dr.  Made- 
lung  (cit.). 

F. 

29 

R. 

Pulsating   vascu- 
lar tumor  back 
of  head. 

24  y'rs. 

• 

fi 

L           do. 
do.  1856. 

Bushe,  G.,  1827. 

Byrd,  W.  A. 
(111.),  1876. 

F. 

M. 

F. 
M. 

29 
34 

2^ 

Mid 
age. 

L. 
L. 

R. 
L. 

6 

Longworth  Prize  The- 
sis ;  Dr.  Madelung 
(op.  cit.);  Schmidt 
Jahrb.,  vol.  xcviii.  p. 

341. 
Lancet,  18-28,  vol.  ii. 
p.  413  ;  Longvrorth 

Prize  Thesis. 

N.  Y.  Med.  Jr.,  Aug. 

1876. 

Eetro-pharyngeal 
tumor  (prepar.  to 
remove). 

Above 
digas- 
tric. 

do. 

7 

g 

pulsating  tumor 
temporal  region. 
Shot  wound   ext 
and   int.   carotid 
angle  of  jaw. 

7  hours. 

9 

10 

f     V.  Bruns, 
1           1856. 
- 

do. 

do.  1859. 

Arch.  Klin.  Chir., 
vol.  xvii.;  Dr.  Made- 
lung. 

M. 

25 

R. 

L. 

R. 

Vascular  tumor 
left  cheek,  lip, 
and  nose, 
do. 

Tumor  of  parotid. 

Arch.  Klin.  Chir., 
vol.  xvii.;  Dr  Made- 

M. 

56 

12 

do. 

Bramblett, 
W.  H.,  1864. 

lung. 

M. 
M. 

23 

47 

L. 
L. 

Fibroid   tumor  of 
parotid. 
Shot  w'nd  cheek. 

13 

N.  Y.  Med.  Record, 
June,  1869. 

10th 

day 
after 

injury. 

14 

De  Castro,  1864. 

Gaz.  Med.  d'Orient, 
1864,  p.  166;  Dr.  Made- 
lung. 

M. 

31 

R. 

Hem.  after  Ms,,  of 
common   carotid 
for  aneur.  exter- 
nal. 

10 

Corradi,  Italy, 
1874. 

N.  Y.  Med.  Jr.,  Sept. 
1876. 

58 

L. 

Tumor  of  parotid. 

16 

Cleary,  1864. 

Arch.  Klin.  Chir., 

vol.  xvii.  p.  626,  Dr. 

Madelung. 

M. 

Mid 
age. 

E. 

Shot  wound  face. 

17 

Demarquay, 

1867. 

Gaz.  Hebdom.,  1858,  p 

6SS. 

M. 

62 

R 

TT■,rr.or•^t.,^TllTO•     nf 

Above 
digas- 
tric. 

parotid. 

THE    EXTERNAL    CAROTID    AHTEIiY. 


107 


External  Carotid  Artery. 


No. 


Date  of 
operation. 


a  Sii 

a>  o  rt 


5    O   o 


.SP(s  i».    Recovery. 


Coudition. 


Sept.  1873. 


f  Aug.  25, 
I        1872. 


do. 

1856. 


Once. 


Noae. 


7  1827. 

May,  1876. 

f      1856. 


March  12, 
1859. 

Aug.  2, 

lS.")f). 

Dec.  1861. 


1864. 


None. 


Noae. 


(Oc- 
curred.) 


Recovered. 


Recovered 


Recovei-ed. 
Recovered. 


Recovered. 


Recovered. 

Recovered. 
Recovered. 

Recovered. 
Recovered. 


Recovered. 


Cured. 


Cured. 


Not  cured. 
Cured. 


Cured 


No  benefit. 
Cured. 

Cured. 
Cured. 


Cured. 


Cause  of  death, 
date  after  op. 


About  .0  days.  Coma; 
cerebral  exhaust 


REMARKS. 


20minutes.  Exhaus- 
tion from  previous 
hem. 


Died  in  fewminutes. 
Hem ;  exhaustion. 


Recovered.!      Cured. 


35  days. 


External  carotid  flrnt  tied  HOino 
hourH  before  common  As  the 
effect  on  t)io  tumor  wag  not 
marked  this  last  vf^sfol  was 
tiod  aiKi  tho  ligature  nirnovfid 
from  thi;  external.  (As  th';  lie- 
ature  was  tightener!  and  re- 
mained several  hours  in  xttu, 
the  vessel  can  prop'-rly  be  con- 
sidered as  obliterated  by  the 
operation,  tho  inner  coat  being 
cut  and  turned  in  as  is  the  rule 
in  such  cases.) — Avthor. 

After  ligature  of  />xt/-rnaf  earn- 
tiii,  hemorrhage  T?hifh  was  ar- 
rested by  liyature  of  C"mmiin 
and  internal  carotid.  Paralysis 
resulted  after  these  last  two 
vessels  were  secured. 

No  bad  symptoms  followed.  In- 
ternal  carotid  tied  same  opera- 
tion. 


Patient  writes  Dec.  20,  187.3, 
"Aai  not  able  to  work;  appetite 
good;  sleep  badly;  pulsation  in 
tumor  place  is  not  so  well  as 
when  I  was  discharged."  Hem. 
from  the  sloughing  tumor  some 
time  after  op.,  only  very  slight. 

External  ea,rr>tid  as  large  as 
common  trunk. 


Pressure  aad  hot  iron  had  been 
tried  to  arrest  hem.  before  liga- 
ture.    No  hem.  after  operation. 

Hemorrhage  had  been  immense 
before  Dr.  Byrd  arrived.  Inter- 
nal and  common  carotid  were 
also  tied. 


10  days  after  wound  internal 
carotid  tied  ;  hemorrhage  per- 
sisting, common  and  external 
carotids  also  tied.  Hem.  still 
followed,  though  not  so  severe, 
arrested  by  pressure  of  cloth 
soaked  in  tinct.  ferri  chloridi. 

Hem.  not  ceasing  after  ligature 
of  common  carotid,  the  sac  sup- 
purated and  external  tied.  Died 
immediately  from  previous 
hemorrhage. 

(No  details  of  this  case.) 


External  c.irotid  tied  14  days 
after  injury;  3.3  days  later,  on 
account  of  hemorrhage,  com- 
mon carotid  was  tied.  Died  2 
days  later. 


108 


PRIZE    ESSAY. 


Ligature  of  the 


No. 


Name  of 
opera'tor. 


Source  of 
information. 


Cause  of 
operation. 


0.2 

•5 1 


A  a 


18  I  Dolbeau,  1864. 

19  iDiimdnil,  1872. 


27 


Ensign.  W.  A. 
1864. 


Fouoher. 

Giinther,  1845. 

Gutlirie. 


26    Hamilton,  Prof, 
F.  II.,  1838. 
Heine,  C,  1869. 


Longworth  (op.  cit.); 
Madelung  (op.  cit.). 


Schmidt  Jahrb.,  Bd. 
IGO,  p.  16ti. 


Schmidt  Jahrb.,  39-10, 

p.  212  ;  Arch.  Klin. 
Chir.,  vol.  xvii.  p.  624; 
Longwovth  ;  Made- 
lung. 
Med.  Surg.  Hist.  Reb.; 
Dr.  G.  A.  Otis. 


Longworth  ;  Made- 
lung  ;  Gaz.  des  Hop., 

1852,  p.  518. 
Madelung  (op.  cit.). 


Nash.  Jr.  Med.  Surg., 
Feb.  1874. 


Arch.  Klin.  Chir., 
1868  :  Pilz. 


Notes  of  case  from 

Prof.  Hamilton. 

Schmidt  Jahrb.,  147, 

p.  69. 


Jones,  J.  C, 

1S64. 

Lannelongue, 

1873.  (?) 

Legouest. 

Lizars,  Jno  , 

1830. 

Mahojn,M.,]864 


Maisonneuve, 
1849. 


do.  1855. 

do. 
do.  1856. 


do. 
do. 


M. 


M. 


F. 


Med.  Surg,  Hist.  Reb.;   M, 
Otis. 
Schmidt  Jahrb.,  Bd. 
166,  p.  149. 
Arch.  Klin.  Chir., 
18BS  ;   Pilz  (cit.). 
Longworth  Prize  The- 
sis (cit);  Madelnng 

(op.  cit). 
Am.  Jr.  Med.  Sci., 
vol.  xlviii.  p.  276  ; 
Madelung  (cit.);  Lan- 
cet, 1829-30,  vol.  ii.  p. 
64. 


Bull,  de  la  Soc.  de 

Chir.,  vol.  i.  p.  4J0  ; 

Longworth  (cit.); 

Madelung. 


Mem.  de  la  Soc.  de 

Chir.,  1864,  tome  vi.  p. 

211  ;  Longworth  ; 

Madelung  (cit.). 

do. 


Mid 
,ge. 
21 


Mid 

age. 

17 


Hem. abscess  sub- 
max.  region. 

Hem.  polyp,  nose. 


Below 
digas- 
tric. 


Suicidal  wound 
near  angle  jaw. 


Shot  wound  orbit 
and  int.  max. 
artery. 

Hem.  after  ampu 
tating  tongue  by 
ecraseur. 

Hem.  after  remov. 
of  parotid. 

Hem.  removal  of 
tumor  of  neck 


Knife  wound  int. 
carotid  (suicid- 
al). 


Scirrhous   tumor 

of  parotid. 
Hem.  cirsoid  turn, 

scalp  and  ear. 


Shot  fracture  of 

right  inf.  max. 
Sarcoma  of  tongue 

and  face. 
Traumatic  aneur, 

of  orbit. 
Prep,  to  removal 

tumor  sup.  max, 

Shot  wound  inf. 
max. 


5  days. 


Above 
digas- 
tric. 

Below 

digas- 
tric. 
Above 
digas- 
tric. 


June  3.  June  14. 


Several 
years. 


Aneurism   anast. 
temporal  region. 


Carcinoma  of 
tongue. 


do. 

Cancer  of  left  inf 
max. and  tongue. 

Cancer  of  tongue, 
jaw,  and  phar- 
ynx. 


Below 

digas- 
tric. 


Below 
digas- 
tric. 


i  inch 
above 
origin. 


Below 
digas- 
tric. 


Dec.  14. 


Nov.  29. 


THE     EXTERNAL    CAROTID     ARTERY. 


109 


External  Carotid  Artery — continued. 


]>ato  of 
operatiuu. 


1864. 


o  H  » 

3   O  c3 


Recovery. 


Occnr'd 
fi-oui 
nose  ; 
none 
from 
liga- 
ture. 
None. 


July  16, 

1SG4. 


March,  1838 


Dec.  14, 

1S61. 


Dec.  3, 1864 


Oc- 
curred 


Recovered, 


Recovered. 


Condition. 


Cured. 


None. 
Severe. 


None. 
None. 


Jan.  21, 
18.31. 

Nov.  23, 
IS.'j). 
18ot3. 


Recovered. 
Recovered. 
Recovered. 


CauHe  of  death, 
date  after  op. 


Died  on  table.     E.k. 
haustion. 


Cured. 


Recovered. 
Recovered. 

Recovered. 
Recovered. 
Recovered. 
Recovered. 

Recovered. 


Recovered 
fromopei''n. 
Recovered 


Recovered. 


Not  cured. 
Cured. 


Not  cured. 
Cured. 


Cured  (?) 


Cured. 


KEMAUKS. 


Died.     Hem. 
exhaustion. 


Died.  Coma;  not  on 
accouut  lig.  ext 
car. 


The  ligature  did  not  arroHt  hern.; 
tlMTo  viaa  no  liera.  from  seat  of 

ligature. 


Wound  from  angle  of  jaw  to 
larynx,  oponing  into  pharyu-X, 
Horn,  before  operation  was  im- 
mense. 

(Ligature  of  the  external  car- 
otid was  performed  too  late,  as 
patient  could  not  rally  from 
previous  and e.\hau.stiug  hem.) 


Hem.  after  ligature  stopped  by 
ice  and  compress. 

Common  carotid  first  tied  ;  did 
not  arrest  hem.  ;  external  tied 
above  wound  ;  hem!  not  arrest- 
ed until  internal  carotid  was 
seoure^l. 

Internal  jugular  vein  tied  (la- 
teral lig.)  and  common  carotid 
same  time.  8  days  later  ext. 
carotid  tied ;  internal  carotid 
also. 

Disease  returned  and  patient 
died  later. 

0  days  after  lig.  of  ext.  on  ac- 
count of  hemorrhage  the  com- 
mon carotid  was  tied.  Hem. 
from  seat  of  ligature. 


Died  of  disease  some  time  after 
operation. 
Common  carotid  tied  same  time. 

Several  polypi  were  removed 
from  the  ethmoid  bone  during 
operation. 

Ball  entered  angle  left  iuf.  max. 
fracturing  it  ;  passed  beneath 
tongue,  out  right  side  hyoid 
bone  ;  common  carotid  first  tied. 
Hem.  not  arrested  ;  external 
was  ligatured  4  days  after  eom- 
mon. 

21  days  after  lig.  of  external 
carotid,  hem.  ;  26th  and  27th 
hem.,  then  lig.  of  common  and 
internal  carotid  ;  sympathetic 
nervt  included  in  last  lig.  Hemi- 
plegia ensued  after  lig.  of  com- 
mon trunk. 


Patient  died  1  month  later  from 

violence  of  disease. 
Died    60    days    after    operation 

from  violence  of  disease. 
Discharged  in  1}^  month. 


110 


PRIZE    ESSAY. 


Ligature  of  the 


Name  of 
operator. 


Soui-ce  of 
infoimation. 


Cause  of 
operation. 


Maisonneuve, 
1854. 
do. 
do. 


do. 
do. 
do. 


L         do. 

5      do.isse. 

\  do. 

do. 


Marchal,  1835. 

Mastermann. 
Moses,  J.,  1863 

Mott,  v.,  1831. 

McClellan,1871, 
do.  1845. 


McGraw,  T.  A. 

Michigan. 

do. 

Nfelaton,  1858. 


lfoir,1861. 
Pancoast,  G.  L. 
1864. 
Parker,  Prof. 
WiUard,  1838. 
do. 
Peugnet, 
Eugene 
(Fordham). 


do. 


L 
Post,  Prof.  A.C. 

1855. 

do.  1876. 

Richard,  1855. 


Mem.  de  la  Soc.  de 
Chir.,  1864,  tome  vi.  p. 

211;  Longworth. 

Dr.  Madelung  in  Arch 

Klin.  Chir.,  vol.  xvii. 

p.  (J-28. 

do. 

do. 

do. 


do. 
do. 
do. 
do. 


Norris  Contrib.  (cit.^ 
Madelung. 


Arch.  Klin.  Chir.,  Bd. 
17,  p.  616  ;  Madelung 

Med.  Surg.  Hist.  Eeb.; 
G.  A.Otis. 


Am.  Jr.  Med.  Sci., 

vol.  X.  p.  17; 

Dr.  Madelung  (cit.). 

Am.  Jr.  Med.  Sci., 

Oct.  1S72. 

McClellan,  System  of 

Surgery. 

Letter  to  author. 

do. 
Arch.  Klin.  Chir.,  Bd. 
17,  p.  620  ;  Madelung. 

do.  p.  624. 
Med.  Surg.  Hist.  Eeb. 

Letter  to  author. 

do. 

N.  Y.  Med.  Rec,  vol. 

xi.  1876  ;  Letter  from 

Drs.  Katzenbach  & 

Peugnet. 


Letter  to  author. 

do. 

Arch.  Klin.  Chir.,  Bd. 

17,  p.  62ii ;  Madelung  ; 

Longworth. 


Mid 
age 


35 
Mid 


R. 


Carcinoma   phar- 
ynx and  tongue, 
do. 

Carcinoma  of 
tongue. 

Unknown. 

do. 
Carcinoma  of 
tongue. 


Carcin.  of  tongue. 

do. 
Unknown. 


Hem.  puncture  of 
aneur.  (mistaken 
for  abscess). 


Aneur.  anast.  ear. 
Shot  wound  face. 


Melanotic  tumor 
of  parotid. 


Recurrent  tumor 
of  right  parotid. 


Removal  of  tumor 

of  parotid. 

do. 
Hem.  after  remov. 

parotid  tumor. 

Hem.  facial  art. 
Shot   wound   inf. 
max. 
Enlarged  parotid. 

Disease  parotid. 
Osteo-aneurism  of 
lelt  inf.  max. 


Prep,  removal  of 

tumor  of  parotid. 

do. 

Traumatic  aneu- 
rism near  paro- 
tid. 


20  y'rs. 


1  year. 


About 
digas- 
tric. 


Sept.  20 


About 
digas- 
tric. 

At  di- 
gastric. 


Near 
bifurca- 
tion. 
do. 


5  inch 
ab.  bif. 


June  18, 
1864. 


i  inch 
above 
bifur. 
of  com. 


Ab.Jin. 

from 
origin. 


THE    EXTERNAL    CAROTID    ARTERY. 


Ill 


External  Carotid  Artery — continued. 


No. 

Date  of 
operation. 

E  »-  u 

o  3  © 

©  o  « 

loo 
-3 

BUBULT. 

REMARKS. 

Recovery. 

Condition. 

Cauae  of  death, 
date  after  op. 

38 

.39 

40 

41 

(  March  11, 
\      18C4. 
(        do. 
March  21, 
1804. 

J       1854. 
\       1804. 
r  March  28, 
18(54. 

y    do. 

)       18.56. 
\       1856. 

15 

15 
18 

Recovered. 

Recovered. 
Recovered. 

Recovered. 
Recovered. 
Recovered. 

Recovered. 
Recovered. 
Recovered. 
Recovered. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

? 

? 

Not  cured. 

Not  cured. 

Cured. 

4'^ 

48 

(This  ca.se  is  reported  as  cured, 
but  as  the  patient  was  lost  Biglit 
of  33  days  after  operation,  f 
think  it  is  not  safe  to  consider 
it  aH  a  cure. — AiWior.) 

44 

4.') 

4fi 

47 

18 

(It  is  not  certain  that  this  case 
belongs  to  Maisouneuve. — Au- 
tkor.) 

Lig.  of  external  narotid  did  not 
arrest  hem.,  and  common  trunk 
viras  tied  ;  2d  day  after  this  cou- 
vulsion.s,  and  death  in  6  days. 

Part  of  tumor  liffatured  also,  and 
part   cut  away  and  nitrate  of 
silver  applied. 

Ext.  carotid  tied,  hut  failed  to 
arrest  hemorrhage ;  19  days 
after,  common  was  tied,  and 
death  followed  in  2  days. 

Died  1>^  year  later  from  disease. 

In  removal  of  tumor  the  jug.  was 
tied  and  facial  nerve  divi'ded. 

Internal  carotid  was  also  tied, 
and  it  was  thought  that  the 
spinal  accessory  and  pneumo- 
gastric  nerves  were  divided. 

4R 

Jane,  1836. 

After. 

Died.    Hem.  and  ce- 
rebral  complica- 
tions. 

49 

5 

Recovered. 

Cured. 

.-in 

Nov.  26, 
1863. 

1831. 

After. 

21st  day. 

.'il 

12 

17 

Recovered. 

Recovered. 
Recovered. 

Recovered. 

Recovered. 
Recovered. 

Recovered. 

Not  cured. 

? 
? 

Cured. 

Cured. 
Not  cured. 

!S7. 

IS?. 

,14 

.'),') 

.in 

1S5S. 

10,11,18, 
19  day 
aft.  op. 

21 

^1 

3d  day. 

applied,  and  vessel  divided  be- 
tween them. 

iiS 

June  27, 
1864. 

July  12, 
1838. 

59 

fin 

None. 

16 

Recovered. 
Recovered. 

Cured. 
Cured. 

fii 

r  July  16, 
1875. 

July  28, 
1875. 

1855. 

1876. 
18.35. 

5,  6,  7, 
8  and  9 
days. 

After. 

None. 
None. 

After  1st  operation  hem.  from 
aneurism  on  21st,  22d,  and  23d 
July,  aud/rom  seat  of  ligature 
on  24th,  which  was  controlled 
by  pressure  on  common  carotid 
of  same  side.  Next  day  there 
was  hem.  again  from  the  aneu- 
rism in  mouih,  and  the  common 
carotid  of  the  opposite  side  was 
tied  ;  the  hem.  was  not  arrested 
and  the  patient  died.  Autopsy 
showed  that  the  internal  caro't- 
id  on  right  side  was  absent,  the 
common  taking  the  distributio  'I 
of  the  externa?,  which  it  in  re- 
ality loas.  (There  is  but  one 
other  such  anomalous  arrange- 
ment of  the  carotid  on  record. 
This  I  found  in  the  dissecting 
room  in  1876. — Author.) 

fi2 

2  days.    Hem. 

63 

64 

Recovered. 

Recovered. 
Recovered. 

Cured. 

Cured. 
Cured. 

112 


PRIZE    ESSAY. 


Ligature  of  the 


No. 


67 


Name  of 
operator. 


Source  of 
information. 


Richet,  1861. 

Eoser,  1856. 

do. 

do. 

clo. 

do. 
Sands,  Prof. 
H.  B.,1872. 


do.  1874. 

Santesson, 1S53 
Sedillot, 

Scott,  1S.30. 


Smith,  Prof. 
Stephen,  1864. 

Unknown,  1863. 


do.  1862. 

do. 

do.  1864. 

do.  hy  Larry. 

do. 


Vanzetti,  1846. 

Verneuil. 

do.  1870. 

Wallace,  1833. 

Weber,  C.  0. 

Wldmer,  1838. 
Wutzer,  1841. 

do.  1847. 


L'TJnion  Med.,  xii.  p. 

4.5,1861;  Dr.Madelung. 

Arch.  Klin.  Chlr.,  Bd. 

17  ;  Madelnug  (cit.). 

do. 

do. 

do. 

do. 

Personally  to  author. 


Arch.  Klin.  Chir., 
1863;  Dr.  C.  Pilz. 
Longworth  Prize  The- 
sis ;  MadeluQg  (op. 

cit.). 

Lond.  Med.  Gaz.,  vol 

vii.  p.  286. 

N.  Y.  Med.  Jr.,  Jan. 

1874. 


Med.  Surg.  Hist.  Reh.;   M. 
Dr.  G.  A.  Otis. 


Cause  of 
operation. 


.9  wj 


53 


L.   Parotid  tumor. 


Varicose   aneur. 
of  left  ear. 
Carcinoma  of  pa- 
rotid. 

Facial  neuralgia. 

do. 

do. 

Secondary  hem. 
rem.  inf.  max. 


do. 

do. 

do. 

Longworth  Prize 

Thesis. 
Madelung  (cit.). 


Arch.  Klin.  Chir.,  Bd. 
17,  p.  720  ;  l)r.  Made- 
lung. 
Lancet,  Nov.  4,  1871, 
p.  644. 

Gaz.  Heh.,  Nov.  10, 
1876,  p.  709. 

Arch.  Klin.  Chir.,  Bd 
17  ;  Madelung;  Long- 
worth  ;  Lancet,  1833-4, 
vol.  i.  p.  849. 
Dr.  Madelung. 


Dr.  Madelung;  Long- 
worth  (cit.). 
do. 


Mid 
age 


Secondary   hem. 

removal   of    dis 

eased  parotid. 
Removal  of  tumor 

of  parotid  ;  hem. 
Vascular   growth 

of  head  and  face. 

Prep,  to  removal 
of  sup.  max.  for 
osteo-sarcoma. 

Hem.  cancer,  dis- 
ease. 

Shot  wound  inf. 
maxilla. 


Shot  w'nd  malar 
hone. 

Shot  wound  sup. 
maxilla. 

Shot  wound  zygo- 
matic region. 

Wound  of  exter- 
nal carotid. 

Removal  scirrhus 
of  ear. 


Enlarged  parotid. 


Shot  w'nd  cheek. 


Prep,  to  removal 
of  osteo-sarcoma 
of  inf.  maxilla. 

Nebvus  of  right 
cheek. 


Parotid   tumor 
(during  remov- 
al). 

do. 

Fung,  of  palate. 


Fung,  of  neck  and 
fauces. 


Few 
minutes 


Below 
digas- 
tric. 


=s  2 

fi  a 


At  di- 
gastric. 

Just 
above 
origin. 


21  days 


Sept.l4 

Sept.l4.  Sept.l 

,Tune  6.   6th  and 
7ih. 


5  inch 
above 
origin. 
Below 
digas- 
tric. 


THE    EXTERNAL    CAROTID    ARTERY. 


113 


External  Carotid  Artery — continued. 


Dato  of 
oporatioii. 


Oct.  22, 
1872. 


Jan.  28, 

1874. 


Nov.  U, 
1853. 


Nov.  17, 
1830. 


Jnly  5, 
1863. 

July  S, 
lSti3. 


Sept.  22, 

18(32. 
Sept.  1.5, 

1832. 
June  7,1864. 


Jan.  19. 
1870. 


la  CD  P< 


None 

fi'om 

ext. 

carotid 


None. 


None. 


None. 


Once  ; 
arti-ry 

retied. 


16,17 
days. 


None. 


Once. 


(2) 
19-22 


Kocovery. 


Kocovored 

Kocoveiod. 

Recovered 

llecovered 
Recovered 
Rocovereil. 
Kecovei'ed. 


Recovered 

Recovered 
Recovered. 

Recovered. 

Recovered. 

Recovered 


Recovered. 
Recovered. 


Recovered. 
Recovered. 


Recovered. 


Recovered. 

Recovered. 
Recovered. 

Recovered. 


Condition. 


Cured. 

Cured. 

Cured. 

No  relief. 
No  relief. 

Cured. 

Cured. 


Cured. 


Cured. 


Cured. 


Cured. 


Improved. 


Cured. 


Cause  of  death, 
dale  after  op. 


12  days.    ? 


42  hours.     Coma. 


19th  day  after  ext. 
2d  day  after  com. 


RKMAKKS. 


Several  Hmaller  veHselH  tied  Hame 

time. 
Patient  wont  home  6  days  after 

operation. 


During  removal  of  lower  jaw  for 
malii,'nant  disease,  the  external 
carotid  and  internal  jugular 
vein  were  secured.  About  10 
days  later  severe  hemorrhages 
occurred  from  ulceration  of  in- 
ternal cnrntid,  and  it,  with  the 
common,  was  liiiatured. 

The  lingual  was  also  tied. 


Ligature  enma*4ewith  internal 

caroti'1. 
Two   ligatures  ;   artery  divided 

between  them. 


Internal  carotid  tied  same  time. 
Patient  died  of  extension  of  di  — 
ease. 

Artery  tied  on  account  of  hom. 
Patient  was  rated  as  "  totally 
disabled."  (In  all  probability 
he  was  disabled  from  wound, 
not  from  the  ligature  of  the  ex- 
ternal carotid.; — Author. 


(Note. — Dr.  Madelung  gives  one 
other  case  by  an  unknown  sur- 
geon, in  which  the  common  and 
external  carotids  were  tied.  As 
Dupuytren  thinks  this  case  is 
uncertain,  I  have  left  it  out. — 
Author.) 


Internal  and  external  in  com- 
mon loop.  The  common  carotid 
tied  same  time. 

Hem.  17th  day.  Common  tied  ; 
death. 


2  ligatures  to  artery. 

Hem.  after  operation  from  the 
occipitalis. 


SUMMARY  OF  THE  SURGICAL  HISTORY 


COMMON,  EXTERNAL,  AND  INTERNAL  CAROTID 
ARTERIES. 


SECTION   1. 

Sex. — The  statistics  contain  789  cases  of  ligature  of  the  Common 
Carotid.  The  sex  is  stated  in  712.  Males,  538.  Females,  174:. 
Three  males  being  exposed  to  accidents,  or  suffering  from  lesions, 
necessitating  this  operation,  to  one  of  the  opposite  sex. 

Age. — The  age  is  stated  in  5-1:2  of  789  instances  as  follows: — 

Under    1  year  old 16 

22 

57 

151 

106 

89 

55 

40 

6 

542 

The  oldest  patient  was  75  years;  the  youngest  6  months  of  age. 
In  the  period  of  life  from  20  to  40,  about  one-half  of  the  opera- 
tions were  performed. 

Side. — Of  the  651  cases  noted  as  to  this  feature — 

361  were  tied  upon  the  I'iglit  side. 
290         "  "  left      " 

The  difference  in  favor  of  the  right  side  may  be  explained,  inas- 
much as  the  carotid  of  this  side  is  often  involved  in  lesions  of  the 
right  subclavian,  which  last  vessel  is  often  the  seat  of  injuries  result- 

(115) 


From 

1 

to  10  years 

10 

"  20   " 

20 

"  30   " 

30 

"  40   " 

40 

"  50  " 

50 

"  60  " 

60 

"  70  " 

70 

"  80  " 

116 


PRIZE    ESSAY. 


iug  from  the  use  by  preference  of  the  right  arm,  also  in  aneurism 

of  the  innominate. 

The  jj.omi  of  deligation  was  at  the  omo-hyoid   muscle  (its  anterior 

belly)  in  the  vast  majority  of  cases,  although  not  stated.     It  is  given 

as — 

Above  the  omo-hyoid  in 56 

At  "  '•  " 4 

Below    "  "  " 25 

The  remainder  not  definitely  stated.  In  one  case  (No.  789)  the 
left  carotid  was  reached  from  behind  the  sterno  mastoid. 

Hemorrhage  is  given  as  occurring  after  the  operation  of  deligation 
in  144  instances.  Unfortunately  meagreness  of  detail  in  the  pub- 
lished reports  renders  it  impossible  for  me  to  specify  whether  the 
bleeding  was  at  the  seat  of  ligature  or  beyond  it,  in  every  instance. 

In  27  instances  it  is  specified  that  no  hemorrhage  occurred  after 
the  ligature  was  applied.  If  there  was  or  was  not  hemorrhage  after 
deligation,  in  the  618  remaining  cases,  it  is  not  specified. 

If  we  admit  that  in  these  618  cases  no  bleeding  took  place^  we  would 
have  only  18  per  cent,  of  hemorrhage  after  ligature  of  the  common 
carotid.  But  when  we  are  reminded  that  many  cases  proved  fatal 
so  soon  after  the  operation  that  secondary  hemorrhage  had  not  the 
time  to  occur  (the  dates  of  death,  in  which  288  of  the  323  fatal 
cases  are  given,  show  that  y'j  died  on  the  day  of  operation,  \ 
within  the  third  day  after,  and  |  within  the  first  week),  and  that 
the  hemorrhage  did  occur  in  a  fair  number  of  cases  in  which  it  is 
not  reported,  it  is  evident  that  this  accident  after  ligature  of  the 
common  carotid  will  occur  in  a  much  larger  proportion  of  cases  than 
18  per  cent. 

Hemorrhage  was  immediate  after  deligation  in          ...  3  cases. 

"          occurred  in  from  1  to      5  days        "          .         .         .  19  " 

5  "     10     "           "          ...  13  " 

"      10  "     20     "            "...  23  " 

"      20  "     40     "           "          .         .         .  10  " 

"      40  "     80     "           "          .         .         .  7  " 

"      80  "  100     "           "          .         .         .  1  " 

"                 "            on     120th  day                 "...  1  " 

"  "  "      11th,  14th,  and  61st  day  in       .         .1  " 

"                "           with  no  date  given  in       .         .         .        .  66     " 


144 


S  U  11  a  T  C  A  L    HISTORY    OF    C  A  R  O  'I'  [  D     A  R  T  K  \i  T  K  S . 


117 


LIGATURE    CAME    AWAY. 

The  date  of  separation  of  the  ligature  is  obtained  in  287  instances 
as  follows  : — 
On  tlie 


41h  flay 

1    0 

n  the  23(1  day 

9 

5   " 

1 

24   " 

4 

7   " 

4 

25   " 

5 

8   " 

5 

26   " 

3 

9   " 

^ 

27   " 

5 

10   " 

10 

28   " 

7 

11   " 

12 

29   " 

3 

12   " 

19 

30   " 

3 

13   " 

25 

31   •' 

I 

14   " 

34 

33   " 

2 

15   " 

16 

34   " 

1 

16   " 

12 

35   " 

2 

17   " 

14 

36   " 

1 

18   " 

17 

39   " 

1 

19   " 

7 

45   "      .    . 

1 

20   " 

9 

48   " 

1 

21   " 

23 

60   " 

1 

22   "     .    . 

11 

96   " 

1 

One  is  given  as  not  having  come  away  at  the  end  of  three  months. 

In  some  few  of  the  later  dated  cases  the  "Lister  carbolized  catgut" 
was  used  as  the  ligature,  and  these  never  came  away,  being  cut  off, 
left  in  the  wound,  and  absorbed.  In  two  cases  the  artery  was  "con- 
stricted," once  with  Dr.  Speir's  constrictor  and  once  with  a  thread.^ 


EESULT. 

Of  789  cases  in  which  the  common  carotid  was  tied  for  all  causes, 
323,  or  41  per  cent.,  died. 

Condition  after  Recovery. — 466  patients  recovered,  as  reported  by 
the  operator,  and  the  condition  is  stated  in  371  of  these,  as  follows  : — 

As  cured .  253 

'•   improved 49 

"   temporarily  benefited        . 14 

"    not  cured 33 

Cured  of  original  disease,  but  with  paralysis  of  opposite  side  as 

a  result  of  the  ligature 2 

As  not  benefited 19 

"    worse  than  ever         .........  1 

Of  the  reported  cases  68  per  cent,  were  cured,  in  the  true  sense  of 
that  term,  and  it  is  probable  that  this  percentage  will  represent  the 
-correct  proportion  of  ewes  in  the  entire  number  of  recoveries. 

'  In  Porcher's  case  (see  Appendix  to  Common  Carotid  Statistics),  catgut  ligature 
w  as  used,  which  became  loose,  and  ihe  artery  was  not  occluded. 


118 


PRIZE    ESSAY. 


DATE  OP  DEATH  AFTER  DELIGATION. 


Of  323  fatal  cases  in  the  total  of 

Immediately  ("upon  the  table")  in 
On  the  same  day  of  the  operation  in 
From  1  to      3  days  after  in 
"      3  "       7      " 

u  14  u  21  " 

"  21  "  28  " 

"  28  "  35  " 

"  35  "  42  " 

«  42  "  50  " 

"  50  "  60  " 

"  60  "  70  " 

"    80  "     90     " 

"100  "  120      " 

"120  "  150      "         " 
Several  weeks  after    • 
No  date  given    . 


789 


',  death  occurred — 

4  instances. 
18 
43 
64 
57 
40 
12 
10 

9 

9 

3 

9 

4 

1 

2 

2   . 

1 
35 

323 


Or  7f  per  cent,  died  within  24  hours,  23  per  cent,  within  3  days, 
45  per  cent,  within  1  week,  64  per  cent,  within  14  days,  and  75  per 
cent,  within  21  days  of  the  date  of  operation  of  deligation. 


CAUSE  OF  DEATH. 


In  only  200  of  the  323  fatal  cases  is  the  cause  of  death  stated. 
From  cerebral  complications  alone,  following  the  ligature,  there 


died     .... 

. 

. 

54  cases. 

From  cerebral  complications, 

with  ' 

'  exhaustion"    . 

4     "    . 

U                                                    (f 

hemorrhage    . 

6      " 

u                                    a 

injury  or  shock 

1      " 

11                                   <( 

pyaemia 

1      " 

•■<(                                    << 

original  disease 

2      " 

(<                                   « 

gastric  fever 

1     " 

From  meningitis     . 

1      " 

"             "            with  hemorrhage 

. 

1      " 

Thus  of  200  fatal  cases,  27  per  cent,  died  from  interference  with 
the  functions  of  the  cerebrum  alone,  by  cutting  off  the  supply  of 
blood  through  one  or  both  common  carotids. 

While  in  15  additional  instances  (7|-  per  cent.)  interference  with 
the  cerebral  circulation  was  an  important  factor  of  death. 


SURGICAL    HISTORY    OF    CAROTID    ARTERIES.  119 

This  point  demands  the  most  earnest  consideration.  I  do  not 
think  it  has  heretofore  been  empliufiized  sufficiently.  I  hold  it  to  be 
an  overwhelming  argument  against  tying  the  common  carotid^  wlien 
tlic  lesion  is  in  the  external  curotid  ox  its  branches,  at  a  point  suffi.- 
ciently  removed  from  tiie  bifurcation  of  the  p-imiiive  carotid  to 
allow  the  ligature  on  the  cardiac  side. 

This  will  be  more  fully  shown  in  the  comparison  of  the  sum- 
maries of  the  external,  with  that  of  the  common  carotid. 

HEMORRHAGE  AS  A  CAUSE  OF  DEATH. 

Of  200  cases  in  which  the  cause  of  a  fatal  result  is  stated — 

Died  from  hemorrhage  alone  from  the  carotid 44 

"  "             with  "  exhaustioa" 12 

"  .    "                "     shock 2 

"  "  "     inflammation  of  thoracic  viscera  .         .  2 

"  "                "     erysipelas 1 

"  "  "     spasm  of  the  glottis      ....  1 

"  "  "     diarrhoea       ......  1 

"  "                "     asphyxia 3 

66 

This  gives  a  ratio  of  mortality  of  22  per  cent,  from  hemorrhage 
alone  after  the  ligature,  while  in  33  per  cent.  (22  additional  cases) 
bleeding  was  a  factor  of  death,  following  the  deligation. 

(Indirect  and  fatal  hemorrhage  came  from  the  vertebral  in  several 
instances,  from  the  jugular  vein  iu  2,  and  from  the  lungs  in  one 
instance.) 

"  EXHAUSTION"  AS  A  CAUSE  OF  DEATH. 

From  exhaustion  alone  there  died  23  cases. 

This  vague  term  may  imply  cerebral  interference,  hemorrhage, 
suppuration,  etc.,  and  is  necessarily  useless,  unless  the  particular 
cause  of  the  exhaustion  is  also  given.  (See  Hemorrhage  and  Cere- 
bral Complications  for  other  cases  in  which  "  Exhaustion"  is  noted 
as  a  factor  of  death.) 

The  original  disease  for  the  cure  of  which  the  operation  was  per- 
formed was  the  cause  of  death  in  .....         7  cases. 
Intercurrent  disease  was  the  cause  of  death  in  .         .         .         3     " 
PyiBmia  alone               "               "               "  ...       12      " 
"         with  pleuritis                "               "                  .         .         .         1      " 


120                                                       PRIZE  ESSAY. 

Inflammation  of  thoracic  viscera  alone  was  the  cause  of  death  in  4  capes. 

Tetanus  alone  "  "  "  1 

Glossitis  alone  "  "  "  1 

OEdema  of  the  glottis  alone  "  "  "  2 

Diarrhoea  .alone  "  "  "  1 

Asphyxia  alone  "  "  "  3 

Inflammation  of  aneurismal  sac  "  "  "  2 


CASES  IN  WHICH  SYMPTOMS  OF  CEREBRAL  DISTURBANCE  WERE  NOTED 
AS  A  RESULT  OF  TYING  THE  COMMON  CAROTID  ARTERY  (FATAL  AND 
NON-FATAL  cases). 

Hemiplegia  opposite  to  side  of  ligature  is  noted  in    .         .         .     43  cases. 
"  "  "  "         with  aphasia         .         .       1      " 

"  on  same  side  as  ligature  is  noted  in        .         .         .       1      " 

Paralysis  of  face  on  same  side,  and  of  body  on  side 

opposite  to  that  of  ligature,  is  noted  in  .         .         .      *  .       2      " 

Paralysis  of  opposite  arm  (none  of  leg)  in         .         .         .         .       5      " 

Imbecility  as  result  of  ligature  in 1      " 

Delirium,  convulsions,  headache,  and  other  light  symptoms  of  cerebral  disturbance 
(not  counting  difficult  deglutition  which  was  in  most  cases  a  mechanical  hindrance) 
occurred  in  18  other  instances. 

If  then  it  is  accepted  that  paralysis  followed  ligature  of  the  com- 
mon carotid  in  only  52  of  the  789  given  cases,  we  have  not  quite  7 
per  cent,  in  which  we  may  expect  this  danger  to  ensue. 

It  is  very  important  in  this  connection  to  remember  that  7|  per 
cent,  of  the  323  fatal  cases  terminated  within  a  few  minutes  to  24 
hours  after  the  deligation  ;  23  per  cent,  inside  of  three  days ;  45 
per  cent,  within  one  week  ;  6i  per  cent  within  14  days  ;  75  per  cent, 
within  21  days,  and  that  after  either  of  these  dates  paralysis  might 
have  resulted. 

Secondly,  remember  that  paralysis  very  likely  did  occur  in  some 
of  the  cases  to  which  no  history  proper  is  attached. 

Thirdly,  that  paralytic  symptoms  would  probably  not  be  recog- 
nized in  patients  operated  upon  in  conditions  of  extreme  prostration, 
when  both  motion  and  intelligence  were  suspended. 

Taking  these  points  into  consideration,  I  am  of  the  opinion  that 
a  larger  percentage  than  that  given  in  the  foregoing  summary  should 
be  present  in  the  mind  of  the  operator  who  has  the  choice  between 
deligation  of  the  common  and  external  carotids. 

In  exceptional  cases  paralysis  will  remain  after  recovery  from  the 
operation  as  a  permanent  malady. 

In  42  cases  of  the  entire  statistics  it  is  noted  that  there  were  "no 
symptoms  of  cerebral  disturbance." 


SURGICAL     HISTORY     OF     CAROTID     AIITKIMIOS.  121 


REPORT   OF    AUTOPSY. 

Post-mortem  examinations  were  reported   in  only  85  of  tlie  »323 
fatal  instances.     In  18  of  these  the  brain  was  not  examined. 

The  points  of  interest  in  connection  witli  this  organ  are  as  follows  : 

Brain,  softened  in 16 

"       inflained              8 

"       anaemia  of          . 1 

"       extravasation  of,  blood      . 1 

"       abscess  of 7 

"            "       and  softening 1 

34 

Showing  that  in  67  examinations  of  the  brain  51  per  cent,  de- 
veloped important  changes  to  have  occurred. 

SYNOPSIS  OF  LIGATURE  OF  THE  COMMON"  CAROTID  WITH  ONE  OR  MORE 
OF  ITS  BRANCHES,  OR  OF  THE  INTERNAL  JUGULAR  VEIN. 

Common,  external,  and  internal  carotids  tied  in  the  same  patient.     Died  2  ;  cured 

2  =  4  cases. 
Common,  external,  and  internal  carotids,  and  the  internal  jugular.     Died  1  ;  re- 
covered 1  =  2  cases. 
Common  and  internal  carotids  in  same  case.     Died  4  ;  cured  2  =  6  cases. 
Common  and  external  carotids  in  same  case.     Died  5  ;   recovered  4;    cured  3  = 

9  cases. 
Common  carotid  and  internal  jugular  vein.     Died    7 ;    recovered  2  ;    cured,  1  = 

9  cases. 
Common   carotid   and  external  and  internal   carotid  and  sup.  thyroid.     Died  1  = 

1  case. 
Common  carotid  and  sup.  thyroid.     Died  1 ;  cured  1  =  cases  2. 

"         "  "     lingual.     Died  1  =  1  case. 

"         "         temporal,  auric,  and  occipital.     Recovered  1  =  1  case. 

"         "         and  internal  maxillary.     Recovered  1 ;    cured  1  =  2  cases. 

"         "  "     temporal.     Recovered  1  =  1  case. 

RE-LIGATURE  OF  THE  COMMON  CAROTID. 

The  same  vessel  was  twice  tied  in  8  instances.     Of  these  6  died. 
The   same  vessel  was   tied  a   third   time  to  arrest   hemorrhage. 
It  proved  fatal. 


122 


PRIZE    ESSAY. 


SYJfOPSis  OF  Cases  in  which  both  Common  Carotids  were  tied. 


CAUSE. 

Age, 
y'rs. 

Interval. 

Result. 

Cause  of  death. 

Operator. 

Malig.  dis.  antmm. 

53 

2|  mos. 

Died  38th  day. 

Exhaustion. 

Wood. 

11              i( 

45 

1       " 

Rec.  (Not  imp'd.) 

Parker. 

(t              (( 

38 

28  days. 

"     improved. 

" 

((                 a 

21 

8  mos. 

11                    u 

V.  Mott. 

"         nose. 

? 

10     " 

"     cured. 

" 

"         orbit. 

? 

5     » 

Died  4th  day. 

(t 

"         parotid. 

? 

15  min. 

"     48  hours. 

Coma. 

(( 

Fungus  hferaat. 

15 

3  weeks. 

Recovered. 

Blackman. 

Aueur.  anast. 

H 

4    mos. 

i( 

Gundelach 
and  Moeller. 

"            occiput. 

53 

H   " 

"           cured. 

Kuhl. 

U                            (( 

20 

1  year. 

"               " 

Pirogoflf. 

Pulsat.  tumor,  orbit. 

20 

28  days. 

K                           <f 

Foote. 

"          both  orbits. 

? 

30     " 

"          better. 

Maogill. 

Aneur.  orbit. 

22 

14  mos. 

"           cured. 

Buck. 

Erect,  tumor,  face. 

23 

30  days. 

"           better. 

Warren. 

"               ear. 

19 

1  year. 

Died  3d  day. 

Exhaustion. 

UUmann. 

"               frontal. 

19 

8  mos. 

Recov'd  ;  better. 

Roberts. 

"               head. 

11 

6  years. 

"       not  cured. 

Van  Buren. 

"              scalp. 

20 

14  mos. 

"       better. 

Mussey. 

Elephnntiasis,  face. 

34 

6     " 

a              a 

Carnochan. 

Hem.  polypus  nose. 

19 

13     " 

a              (c 

Paul  F.  Eve 
and  V.  Mott. 

"     interna]  carotid. 

27 

13  days. 

Died  3d  day. 

Hem.  ;  coma. 

Billroth. 

"     shot  wound. 

21 

4     " 

Recov'd :  cured. 

Ellis. 

li             '( 

? 

same  d'y 

Died  same  day. 

? 

Unknown. 

a                1' 

? 

3  days. 

"     5th  day. 

Hemorrhage. 

Murdock, 

1(                    u 

? 

6     " 

"     38  hours. 

? 

Longmore. 

(t                    u 

? 

4     " 

"     5th  day. 

? 

Lewis. 

Epilepsy. 

20 

17     " 

Recov'd ;  better. 

Weber. 

u 

? 

6  mos. 

"               " 

V.  Mott. 

<( 

18 

6     " 

"         cured. 

Hamilton. 

"         and  hemipl. 

61 

2i-     " 

"         no  better 

Preston. 

Paralysis. 

24 

li    " 

"         better. 

u 

Unknown. 

H 

4    " 

"         cured. 

Miiller. 

Total,  33.  Died  9,  or  27  per  cent.  Of  the  24  recoveries,  8  are 
noted  as  cured,  11  as  improved,  2  as  no  better,  and  1  as  not  cured. 

Of  the  9  fatal  cases,  4  were  for  gunshot  wounds  and  1  for  hemor- 
rhage. 

The  intervals  in  these  9  cases  were,  respectively,  same  day,  3,  4,  6, 
and  13  days,  15  minutes,  2|  months,  5  months,  and  1  year. 

It  is  impossible  not  to  be  impressed  with  the  comparatively  light 
mortality  following  so  formidable  an  operation. 


Among  the  most  dangerous  complications  of  ligature  of  the  com- 
mon carotid  is  the  following,  which  relates  to  ligature  of  the  right 
subclavian,  the  operations  being  simultaneous  or  with  a  varying 
interval. 


SURGICAL     HISTORY    OF    CAROTID     A  liT  1<J  li  I  K  S  .  123 

SIMULTANEOUS  LIGATURE  OF  COMMON  CAROTID  AND  SUBCLAVIAN 
ON  THE  RIGHT  SIDE.      (FlliST  DIVISION.) 

Ijiston,  subclaviiui  aneurism,  Died   i;')tli  day.  liciiiori'lia'rc. 


Rossi,  imioiniiiate           "             ' 

'       0th     ' 

'    ccreljral  ana;mia. 

Parker,  subclavian         "             ' 

'       42  d 

"    hemorrhage. 

Hobart,  aortic                "             ' 

'     IGth     ' 

u                   u 

Ouvellier,  bayonet  wound           " 

loth     ' 

I                 It 

Kuhl,  vas.  turn,  frontal  region  " 

2d     ' 

'    not  known. 

Of  the  4  cases  in  which  hemorrhage  was  the  cause  of  death,  the 
bleeding  came  from  the  subclavian  in  3,  from  the  carotid  in  one  case. 

SIMULTANEOUS    LIGATURE    OF    COMMON    CAROTID    AND     SUBCLAVIAN 
ARTERIES  ON  THE  RIGHT  SIDE  (THE  LATTER  IN  ITS  THIRD  DIVISION). 

Durham,  innominate  aneurism,   Died       6th     day,  shock. 

Eliot,  "  "  "         25th       "     hemorrhage. 

Ensor,  aortic  and    "  "  '"         65th       "  " 

Holmes,  innominate  "  "         57th       "  " 

Hodges,  "  "  "         11th       " 

Weir,  "  "  "         11th 

Maunder         "  "  "     few  days  (?) 

Sands,  aortic  "     recorded.     (Died  13  months  later  from  aneurism.) 

Heath,  innominate  "  "  (Died  4  years  later  from  the  aneurism.) 

Lane,  "  "  "  (No  improvement.) 

Little  "  or  aortic    "  "  Probable  cure,  1  year  later  doing  well. 

Barwell,'innom.  aortic,  caret,  and  subclav.       "  "     3  mos.     "         " 

(Hemorrhage  occurred  from  tlie  carotid  in  one  of  these  cases.) 

CASES  IN  WHICH  THE  CAROTID  WAS  FIRST  TIED  AND  THE  SUBCLAVIAN 
IN  ITS  THIRD  DIVISION  AT  A  LATER  PERIOD. 

Bickersteth,  aneurism  innom.  and  aorta.    Died^  21st  day  ;  suffocation.    Carotid 

tied  7  weeks  previously. 
Wickhara,  aneurism  innominate.     Died^  3  months.     Carotid  tied  3  mos.  before. 
Speir,  aneur.  aorta.     Died  32  days  ;  hem.    Carotid  "  constricted"  2  days  before. 
Fearn,  aneur.  innom.    Recovered  ;  much  improved.    Carotid  tied  2  years  before. 
Doughty,^  A.  B.  Mott,  aneurism  innominate.      Recovered  ;   cui-ed.     Carotid 

tied  one  year  before  subclavian. 

'  Harwell's  case  died  of  pneumonia  and  bronchitis,  and  other  complications,  three 
months  and  ten  days  after  the  operation.      (See  Carotid  History.) 

2  In  these  last  five  cases  death  is  dated  from  the  deligation  of  the  subclavian. 

3  Prof.  Mott  tied  the  subclavian  in  1876. 


124  PRIZE    ESSAY. 

Of  tlie  23  instances  in  which  the  right  common  carotid  and  right 
subclavian  arteries  have  been  tied,  16  proved  fatal ;  7  recovered,  in 
one  of  which  "  no  improvement"  was  reported,  and  in  3  of  these  7  a 
cure  is  probable.^ 

I  would  conclude  from  the  above:  1st.  That  ligature  of  the  carotid 
and  subclavian  (in  its  first  division)  should  not  be  performed, 

2d.  That  it  will  prove  safer  to  tie  the  carotid  first  (when  it  shall 
be  deemed  necessary  to  tie  both  vessels  in  the  treatment  of  aneurism), 
in  order  to  relieve  the  sac  from  the  danger  of  rupture  to  which  it 
would  be  exposed  by  the  sudden  stoppage  of  the  two  great  vessels 
connected  with  it,  before  the  collateral  circulation  may  have  been 
partially  established. 

3d.  That  the  subclavian  should  be  tied  in  its  third  surgical  di- 
vision. 

LIGATURE  OF  THE  RIGHT  CAROTID  AND  THE  INNOMINATE. 

This  has  been  performed  twice.  Once  by  Smythe  of  New  Orleans. 
The  patient  lived  10  years,  and  died  of  the  original  aneurism,  which 
again  formed  by  the  reverse  collateral  circulation. 

A  second  time  by  A.  B.  Mott.  The  patient  died  soon  after,  of 
hemorrhage  into  the  thorax,  the  sac  bursting.  The  vertebrals  were 
tied  in  both  cases. 

SECTION  2. 

A  SPECIAL  SUMMARY  OF  THE  HISTORY  OF  THE  COMMON  CAROTID 

ARTERY. 

Classification  of  the  various  Lesions  for  which  the  operation  was  made. 

SPECIAL  SUBJECT  :   WOUNDS. 

Divided  into — 

1.  Lacerated. 

a.  Gunshot  wounds  of  military  practice. 
6.  Gunshot  wounds  of  civil  practice, 
c.  Torn  wounds  other  than  gunshot. 

2.  Punctured. 

3.  Incised. 

4.  Wounds,  the  nature  of  which  is  not  given. 

•  For  furtlior  remarks  on   these  cases  the  reader  is  referred  to  the  risum^'  of  the 
subclavian  arteries, 


i 


SURGICAL    IIISTOHY    OP"    CAROTID    AliTEIilKS. 


125 


Lacerated  Wounds. 
The  common  carotid  artery  was  tied  in  134:  instances  on  account 
of  tlie  above  lesions.     Of  these,  87  proved  fatal,  or  66  per  cent. 

Gunshot  Wounds  of  Military  Practice. 


Of  cranial  region     . 

Total  10 

Died    5 

Recovered    5 

"  face  alone 

"     53 

'^    3G 

17 

"  face  and  neck 

"     15 

"    14 

1—1 

"  neck  alone 

"     18 

"    17 

1—1 

"  region  not  stated 

"     15 

"      9 

6 

111 


81 


30 


Fatal  in  73  per  cent. 

That  cranial  woands  appear  to  be  not  more  fatal  is  probably 
owing  to  the  fact  that  when  these  wounds  are  serious  they  are  fatal 
before  assistance  can  be  had  ;  when  not  penetrating,  the  hemorrhage 
is  not  usually  dangerous,  and  the  disturbance  is  not  so  great  as  the 
terrible  lacerations  of  the  neck  and  face.  Naturally  the  result  shows 
that  shot  wounds  of  the  face  alone  are  less  fatal  than  those  of  the 
neck. 

Gunshot  Wounds  of  Civil  Practice. 

Of  the  neck  alone 

"     "     face      "... 

"     "     neck  and  face 
No  region  given 


Total  5 

Died  1 

Recovered  4 

"     7 

"      1 

6 

"     1 

"      0 

1 

"     3 

"      2 

1—1 

16 


12 


Fatal  in  25  per  cent. 

Difference  in  favor  of  civil  practice  48  per  cent. 

Reasons.  1.  Military  projectiles  are  larger.  Have  greater  velocity. 
Cause  greater  destruction  of  tissues  and  more  shock. 

2.  The  soldier  is  excited,  the  circulation  at  its  height ;  as  a  con- 
sequence his  wounds  bleed  more  freely  than  an  accidental  ivound,  as 
are  most  of  those  in  civil  experience.  The  exigencies  of  battle 
prevent  him  receiving  that  prompt  attention  usually  bestowed  upon 
the  civilian.  By  the  time  the  surgeon  reaches  him  and  ties  his 
"  common  carotid,"  he  is  already  so  prostrated  by  hemorrhage  that 
he  either  does  not  rally,  or  dies  from  cerebral  inanition. 

Lacerated  Wounds  {not  Gunshot). 

Of  face Total  1         Died  1         Recovered  0 

Of  face  (arrov^f)          .         ..."      1  "0  "1 

Of  throat "5  "1  "4 


Fatal  in  28  per  cent. 


126  PRIZE    ESSAY. 

These  were  all  in  civil  practice.  (In  Abernethy's  (fatal)  case  the 
laceration  by  cow's  horn  was  very  violent  and  extensive.) 

Punctured  Wounds. 

Total  number  of  cases  33 :  died  15,  recovered  18 ;  rate  of  mor- 
tality according  to  this  result,  45  per  cent.  These  wounds  were 
situated  mostly  in  the  upper  portion  of  the  neck.  In  5  of  tlie  fatal 
cases  the  mistake  was  made  of  tying  the  common  carotid  when  the 
lesion  was  in  the  vertehral^^  the  hemorrhage  being  supposed  to  be 
from  the  branches  of  the  former. 

To  arrive  at  a  better  idea  of  the  rate  of  mortality  following  liga- 
ture of  the  common  carotid  for  punctured  wounds,  we  must  exclude 
from  the  calculation  5  of  the  fatal  cases,  leaving  a  death-rate  of  86 
per  cent.  I  consider  even  this  as  a  high  rate  of  mortality,  since 
pimctured  ivounds  as  a  rule  do  not  cause  profuse  hemorrhage,  exten- 
sive destruction  of  tissue,  or  great  shock.  Doubtless,  some  of  these 
cases  would  have  been  successful  if  both  ends  of  the  bleeding  vessel 
had  been  secured  in  the  original  wound. 

Incised  Wounds. 

Under  this  heading  there  are  18  cases:  died  8,  recovered  10; 
mortality  ^^  per  cent. 

Wounds^  the  Nature  of  which  is  not  given. 

Total  of  this  class  46  :  died  21,  recovered  25 ;  mortality  46  per 
cent. 

The  common  carotid  was  tied  on  account  of  wounds  (other  than 
gunshot  and  lacerated)  in  97  cases,  of  which  44  died  and  58  recov- 
ered, the  rate  of  mortality  being  45  per  cent. 

SPECIAL  subject:  tumors. 

Subdivided  into  ligature  on  account  of — 

1.  Malignant  growths  (not  in  orbit). 

2.  Non-malignant  growths  (not  in  orbit). 

'  The  diflFerential  diagnosis  in  these  cases  is  necessarily  very  difficult  when  we 
consider  the  free  anastomosis  through  the  circle  of  Willis.  Pressure  below  which  only 
occluded  the  carotid  would  not  arrest,  but  would  rather  increase  the  escape  of  blood 
from  the  vertebral,  while  pressure  directly  backward,  below  the  transverse  process  of 
the  6th  cervical,  would  diminish  or  temporarily  arrest  the  bleeding  from  the  vertebral. 


J 


SURGICAL    niSTOUY"    OP    CAKOTII)    AliTEKIES.  127 

3.  Tlemorrliage  from  abscess  or  ulcer. 

4.  Removal  of  superior  maxilla. 

5.  Eeraoval  of  inferior  maxilla. 

1.  Ligature  of  the  Common  Carotid  artery  on  account  of  malig- 

nant growths  of  the  antrum  of  Ilighmore,  parotid  gland,  of 
face,  etc.  etc.  (not  of  orbit).  Total  87  :  died  38,  recovered  49  ; 
death-rate  44  per  cent.  Of  the  49  recoveries,  13  are  re- 
ported cured,  12  as  improved,  10  as  not  cured,  remainder  re- 
ported as  recovered. 

2.  For   (lesions)   growths  termed  non-malignant   (other  than   of 

orbit)  the  common  carotid  was  tied  in  75  cases.     Died  30, 
recovered  45  ;   death-rate  40  per  cent.     Of  45  recoveries,  16 
are  reported  cured,  2  as  improved,  4  as  not  cured. 
It  is  a  little  surprising  that  the  death-rate  in  malignant  diseases 
should  be  no  higher  as  compared  to  non-malignant  affections.     It  is 
probable  that  some  of  the  cases  classed  as  malignant  would  have 
been  placed  with  the  non-malignant  tumors,  had  they  been  investi- 
gated in  the  light  of  more  recent  pathology. 

3.  On  account  of  hemorrhage  resulting  from  ulcerations,  abscess, 

etc.,  the  pri7nitive  carotid  was  tied  in  13  cases.  Recovered  5, 
died  8;  death-rate  61  per  cent.  All  the  recoveries  are  re- 
ported cured. 

4.  Preparatory   to   or   after    removal    of   the    superior    maxilla. 

Total  11:  recovered  8,  died  3;  mortality  28  per  cent.  Of 
the  8  recoveries,  2  are  given  as  cured,  3  as  not  cured. 

5.  Removal  of  inferior  maxilla  18  cases.     Recovered  12,  died  6  ; 

mortality  50  per  cent.    5  of  the  recoveries  are  reported  cured. 
Summary  of  the  foregoing  5  classes:   Total  204:  recovered  119, 
died  85;  mortality  411  per  cent.     Of  119  recoveries,  41  are  reported 
cured,  14  as  improved,  17  as  not  cured,  the  remainder  as  recovered. 

LIGATURE  OF  THE  COMMON"  CAROTID  ARTERY  FOR  RELIEF  OF 
ERECTILE  AND  PULSATING  TUMORS. 

1.  Non- malignant. 

2.  Malignant. 

1.  Non-malignant  tumors  of  the  orbit.  Total  52  cases:  recov- 
ered 46,  died  6  ;  mortality  11|  per  cent.  Of  46  recoveries, 
28  are  marked  cured,  5  as  improved,  6  as  not  improved. 


128  PRIZE     ESSAY. 

The  above  result  must  be  considered  as  very  favorable  indeed. 
The  distance  of  the  diseased  structures  from  the  seat  of  ligature, 
where  the  artery  is  in  a  healthy  condition,  and  which  allows  a  firm 
clot  to  form, before  the  ligature  cuts  through,  is  probably  an  impor- 
tant factor  of  such  a  marked  success. 

2.  Malignant  vascular  tumors  of  the  orbit.     Total  8:    died  4; 

death-rate  50  per  cent.      One  of  the  4  recoveries  is  noted 

cured  (the  eye  being   extirpated    at   the    same    time),  2  are 

given  as  not  cured. 

Ligature  on  account  of  aneurism  by  anastomosis  (other  than  those 

of  the  orbit).     Total  71:   recovered  51,  died  20;  death-rate  28  per 

cent.     Of  the  recoveries  20  are  noted  cured,  9  as  improved,  and  16 

7iot  cured. 

LIGATURE  OF  THE  COMMOISr   CAROTID    FOR    CURE  OF  ANEURISM  (i.  e.  A 
SACCULATED   BLOOD-TUMOR  COMMUNICATING  WITH  AN  ARTERY). 

Subdivided  into — 

1.  Ligature  between  the  aneurism  and  the  heart. 

2.  Ligature  by  mistake  (the  carotid  tied  for  vertebral  aneurism). 

3.  Ligature  on  the  distal  side  of  the  aneurism. 

1.  On  the  Cardiac  Side  of  the  Tumor. 

Total  106:  recovered  69,  died  37;  death-rate  35  per  cent. 

Subdivided  into — 

(a)  For  aneurism  of  the  external  carotid  or  its  branches.      Total 

22 :  died  5 ;   mortality  23  per  cent.     Of  the  17  recoveries, 

16  cured,  1  improved, 
{h)  For  aneurism   of  the  internal  carotid  or  its  branches.     Total 

6 :  died  4  ;  or  66  per  cent.     Of  the  2  recoveries,  1  is  reported 

as  cured. 

(c)  For  aneurism  of  the  common  carotid  alone.     Total  16:  died 

7;  mortality  44  per  cent.      Of  9  recoveries,  8  are  given  as 
cured. 

(d)  For  aneurism  (the  seat  of  lesion  not  given).    Total  62  :  died 

21 ;  mortality  34  per  cent.      Of  41  recoveries,  35  are  noted 

cured,  2  improved,  and  2  as  no  better. 
Summary  of  above.     Of  69  recoveries,  60  were  cured,  and  3  are 
given  improved.    Rest  not  noted.    The  lesions  of  the  external  carotid 
being  least  fatal,  those  of  the  internal  (as  far  as  judged  by  such  a 
small  number  of  cases)  most  fatal. 


SURGICAL   IlISTORY    OF    CAROTID    Ali'l'KIUKS.  129 

2.  Ligature  of  the  Common  Carotid^  for  supposed  Carotid^  hut  in 
reality  Vertebral  Aneurism. 

Total  5.     All  fatal. 

The  difficulty  of  distinguishing  vertebral  from  carotid  aneurism 
in  tlie  neck  arises  from  the  fact  that  direct  pressure  from  before 
backwards,  in  the  lower  portion  of  the  neck,  will  interfere  with  or 
arrest  pulsation  in  aneurisms  of  both  vessels. 

If,  however,  the  head  be  flexed  upon  the  chest,  and  the  sterno- 
mastoid  muscle  tlius  relaxed,  the  carotid  can  be  compressed  by 
grasping  the  muscle  between  the  thumb  and  finger,  which  are 
pressed  deeply  behind  the  outer  and  inner  borders.  This  will  not 
involve  the  vertebral. 

Again  ;  if  the  carotid  be  forcibly  compressed  by  the  thumb,  back- 
ward and  inward,  low  against  the  vertebral  column,  at  any  point 
above  the  transverse  process  of  the  6th  cervical,  the  vertebral  will 
not  be  included,  since  it  is  protected  by  the  processes. 

3,  Ligature  of  the  Common  Carotid  Artery  on  the  Distal  Side  of  the 

Aneurism. 

Subdivided  into — 

(a)  For  aneurism  of  the  arch  of  the  aorta. 

(b)  For  aneurism  of  the  innominate. 

(c)  For  aneurism  of  the  subclavian. 
{d)  For  aneurism  of  the  carotid. 

(a)  13  cases  are  reported  in  which  the  aneurism  was  situated 
upon  the  arch  of  the  aorta  (or  was  supposed  to  be).^  6  died. 
Of  the  7  recoveries^  5  are  noted  improved.  In  4  of  the  13  in- 
stances the  subclavian  was  also  tied,  3  of  these  4  provintr 
fatal.  (These  four  were  thought  to  be  innominate.)  [JSTos. 
8,  104,  106,  113,  274,  275,  288,  387,  495,  577,  652,  779,  784, 
respectively.] 

(Z>)  Innominate  aneurism,  in  which — 

(1)  The  carotid  alone  was  tied. 

(2)  The  carotid  and  subclavian  were  tied, 

(1)  Total  17.  Died  12,  or  71  per  cent.  Of  5  recoveries^  2  are 
cured^  and  2  improved,  and  1  not  cured.  [Nos.  80,  176,  203, 
210,  283,  300,  302,  315,  417,  434,  435,  542,  543,  544,  550, 
715,  771.] 

'  See  notice  of  death  of  Bai'well's  case,  which  termiuated  fatally  since  writing  above. 


130  PRIZE    ESSAY.  * 

(2)  Total  14.  Died  10.  Of  the  4  recoveries^  2  are  most  probably 
cured ;  1  improved ;  and  1  improved  temporarily,  dying  in 
five  months.  [Nos.  191,  196,  200,  208,  2b9,  379,  591,  752, 
753,  778,  781,  782,  783,  784.]  (The  aorta  was  involved  also 
in  some  of  these.) 

(c)  Subclavian  aneurism.  Total  5.  Eecovered  1  (No.  638).  In 
2  cases  the  innominate  was  also  tied  (Nos.  638,  473).  In  2 
others  the  subclavian  was  also  tied  (Nos.  129,  358).  The  case 
(No.  638)  died,  about  ten  years  later,  of  the  old  aneurism, 
which  had  disappeared  and  then  reformed  from  the  recurrent 
collateral  circulation. 

{d)  Aneurism  of  the  carotid.  Total  5.  Died  2.  [Nos.  77,  328, 
736,  737,  757.]     Cured  2  ;  improved  1. 

(e)  In  1  other  case  the  subclavian  was  also  tied.  Eecovery 
(No.  336),  ''not  curcdP 

Summnry  of  Cases  of  Ligature  of  the  Common  Carotid. 

On  account  of  aneurisms.  Total  166  cases.  Died  76,  or  46  per 
cent.      Cured  ^Q^  of  90  recoveries. 

On  cardiac  side  of  aneurism.  Total  106.  Died  37,  or  35  per 
cent.     Recovered  69  ;  cured  60. 

On  distal  side  of  aneurism.^  Total  60.  Dzec?  39,  or  Qb  percent. 
Recovered  21 ;  cured  only  6. 


LIGATURE  OF  THE  COMMON  CAROTID  ARTERY  FOR  THE  RELIEF  OF 
KEttVOUS    DISORDERS. 

Subdivided  into — 

1.  Epilepsy. 

2.  Neuralgia. 

3.  Hemiplegia. 

4.  Headache. 

1.  Epilepsy.  Total  20,  Died  1.  Mortality  5  per  cent.  Of  the 
19  recoveries^  3  are  reported  cured ;  10  improved  (three  of  these  only 
temporarily);    and  3  not  benefited. 

2.  Neuralgia  (of  Head  or  Face).  Total  14.  Died  1.  Of  the 
13  recoveries^  6  were  cured,  4  temporarily  improved,  1  not  benefited. 

'  I  have  included  here  the  five  cases  in  which  the  vertebral  was  the  seat  of  the 
aneurism. 


SURGICAL    HISTORY    OF    CAROTID    ARTEIUKS.  131 

3.  Hemiplegia.  Total  4,  All  rooovorod ;  throe  of  those  arc 
improved ;  1  not  hencJUed. 

4.  Headache  2.     Both  recovered.     Improved  I.     No  bonofit  1. 

Summary  of  Ligatures  for  Nervous  Disorders. 

Total  40.  Died  2.  Mortality  5  per  cent.  Of  38  recoveries,  9 
were  cured;  18  were  henefUc'l ;  no  benefit  in  G;  condition  not  given 
in  rest. 

(The  fact  that  so  few  of  these  patients  died  from  an  operation  of 
such  magnitude  is  probably  due  in  great  measure  to  the  healthy 
condition  of  the  artery  at  the  seat  of  ligature,  and  also  to  the  fact 
that  these  patients  had  not  been  exhausted  by  hemorrhage.) 

SECTION  3. 

SUMMARY  OF  THE  SURGICAL  HISTORY  OF  THE  INTERNAL  AND 
EXTERNAL  CAROTID  ARTERIES. 

(a)  I  have  found  only  18  cases  of  ligature  of  the  internal  carotid  in 

which  definite  results  are  given. 

From  these,  nothing  reliable  as  to  the  practicability  of  this  ope- 
ration can  be  deduced,  since  in  only  one^  instance  was  this  vessel 
alone  the  subject  of  deligation.  In  this  case  (No.  9)  the  operation 
was  successful. 

The  common  and  internal  carotids  were  tied  in  6  cases;  3  recovered 
and  were  cured ;  3  died. 

The  external  and  internal  carotids  were  tied  in  3  cases.  All  re- 
covered;  1  was  cured. 

The  common,  internal  and  external  carotids  were  tied  in  6  cases; 
3  recovered ;  2  of  these  were  cured;  3  died. 

The  internal  jugular  YG\n  and  the  internal  carotid  wqvq  iieiWn  1 
case.     Recovered, 

The  common,  internal  Q.n^  external  carotids  and  the  internal  jugular 
vein  were  tied  in  1  case.    Recovered. 

Summary.  Total  18.  Died  6,  or  33  per  cent.  Of  the  12  re- 
coveries, 8  were  cured ;  1  not  cured;   rest  noted  as  recovered. 

The  cause  of  the  operation  was — ■ 

Hemorrhage  in  14  cases,  of  which  5  died. 
Erectile  tumor       1  case,  1     " 

Aneurism  1     "  0 

16  6 

Not  given  in  2. 

'  Since  writing  this  a  second  case  has  been  reported  of  ligature  of  this  vessel  alooe. 
Recovered  ;  cured.     See  foot-note  under  Statistics  of  Internal  Carotid. 


132 


PRIZE    ESSAY. 


The  cause  of  death  as  given  is — 

Pyaemia  in  1  case. 

Exhaustion  and  heraorrhage  in  1  case. 
"  "     shock  in  1  case. 

Hemorrhage  alone  in  1  case. 

Coma  alone  in  1  case. 
(The  operation  will  be  considered  in  the  closing  summary.) 

(h)  Summary  of  the  ligatures  of  the  external  carotid.    The  statistics 

give  91  instances  in  which  the  external  carotid  artery  has   been 

ligatured. 

Of  these  14  died,  or  15  per  cent.;  but  in  10  of  these  fatal  cases 
the  common  carotid  was  also  tied,  leaving  only  4  deaths  out  of  81  cases 
in  which  the  ligature  of  the  external  was  not  complicated  with  that 
of  the  common  carotid. 

If  however  we  exclude  all  complications,  and  select  only  those 
cases  in  which  the  external  carotid  alone  was  tied,  we  will  have  a 
better  idea  of  the  result  of  this  operation. 

Of  these  the  statistics  contain  67  cases,^  with  three  deaths.  Rate 
of  mortality  4|  per  cent. 

These  three  fatal  cases  were  gunshot  wounds  in  military  practice^  ac- 
companied hy  prostration  and  extensive  injury.  One  died  on  the  table 
from  loss  of  blood  before  the  operation  ;  the  cause  of  death  is  not  given 
in  the  other  two. 

Of  64  recoveries,  31  are  reported  cured ;  12  as  not  cured;  and  1  as 
improved.     Remainder  not  noted  as  to  condition. 

Hemorrhage  after  ligature  in  these  67  cases  occurred  in  5,  none  of 
luhich  proved  futal.  It  was  from  the  seat  of  lesion  beyond  the  ligature 
in  4 ;  the  location  not  noted  in  1  case. 

Of  these  67  cases  the  sex  is  given  in  47,  of  which  34  were  males; 
13  females. 

l}\iQ  side  of  body  \s  given  in  49  instances.^  Upon  the  right  side 
in  31;  the  left  in  18. 

Age — 

Between    1  and  10  years  of  age 1  case, 

4  cases. 


10  ' 

'  20 

20  ' 

'  30 

30  ' 

'  40 

u    40  < 

'  50 

50  ' 

'  60 

60  ' 

'  70 

1  On  account  of  the  peculiarly  abnormal  arrangement  of  the  bloodvessels  I  have 
omitted  Dr.  Peugnet's  case  from  this  summary. 

2  The  artery  was  tied  on  both  sides  in  the  same  patient  in  6  instances,  all  of  whom 
recovered. 


SURGICAL    HISTORY    OF    CAROTID    ARTERIES. 


133 


The  ligatures  came  away  as  follows  (being  tlio  only  cases  noted 
as  to  this  feature  in  the  entire  91  histories). 


5th  day 

.     1 

17tli  clay  . 

.     1 

7       " 

.     1 

18       '•      . 

.     4 

8       " 

.    4 

19        "      . 

.     1 

10       " 

.     2 

20       "      . 

.     1 

12 

.     2 

21       "      . 

.     1 

13 

.     I 

22       "     . 

.     1 

14       " 

.     1 

— 

15       '' 

.     4 

Total 

.  26 

16        " 

.     4 

• 

In  the  67  cases  of  ligature  of  the  external  carotid  alone,  the  causes 
of  operation  were,  as  far  as  given,  as  follows : — 

On  account  of  tumors  of  the  i^cLTO^-id  gland  (before,  during,  or  after 

removal  of). 

Non-malignant  17 ;  all  recovered.  Cured  15  ;  not  cured  1 ;  noted  as  recovered 
1.     Malignant  3  ;  all  recovered.     Not  cured  2  ;  cured  1  =  20  cases. 

For  affections  termed  malignant  (other  than  those  of  parotid). 

Fungus  of  palate  ;  recovered  1.  Fungus  of  neck  and  fauces  ;  recovered  1.  Sar- 
coma of  tongue  and  face  ;  recovered,  not  cured,  1.  (Jarcinoma  ;'  I'ecovered,  cured,  4  ; 
recovered,  not  cured,  2  ;  noted  as  recovered  3  =  12  cases. 

[If  to  these  12  cases  are  added  the  3  other  "  malignant"  cases  of 
the  parotid,  we  have  15  instances  in  which  this  artery  was  tied  to 
relieve  or  cure  so-called  malignant  growths,  with  5  cures  and  no 
deaths.] 

Gunshot  wounds  of  lower  jaw  3;  recovered  2;  died  1.  Gunshot  wounds  of  malar 
region  and  sup.  max.  3 ;  recovered  2  ;  died  1.  Gunshot  wounds  of  orbit  1 ;  died  1 
=  7  cases. 

For  wound  of  external  carotid 

"         "  facial  artery 

Hemorrhage,  removal  of  tongue 

"  abscess  of  submax.  region    . 

"  polypus  of  nose  .         .         . 

"  remov.  pulsating  tumor  temp. 

"  "       tumor  pharynx 

Aneurism  in  the  parotid 
Varicose  aneurism  of  ear 
Vascular  growth  (nsevi,  etc.)  of  cheek     . 
"  "  "  head  and  face 

"         growth^  back  of  head 
"         growth^  cheek,  lip,  and  nose 
Removal  of  sup.  maxilla  osteo-sarcoma    . 


2     Re 

^covered,  cured  2 

" 

(( 

li              It 

a 

11                    11 

11                    11 

II                    II 

II                    fi 

"     improved. 

" 

"     not  cured. 

"     no  better. 

"     cured. 

11 

'  In  three  of  these  both  carotids  were  tied. 


2  Both  carotids  tied. 


134 


PRIZE    ESSAY. 


Facial  neural^'ia 


Cause  unknown' 


1  Recovered,  no  improvement. 

1 

1         "         cured. 

1         "         cured. 

1 


HEMOREHAGE. 

Of  the  91  cases  given  in  the  table,  hemorrhage  is  stated  to  have 
occurred  after  ligature  of  the  external  carotid  either  at  the  seat  of 
ligature  or  beyond  it  in  12  instances,  or  about  13  per  cent.^ 

In  6  of  these  12  it  was  deemed  expedient  to  tie  the  co^mmon  or 
internal  carotids  or  .both,  afterwards.  In  one  case  the  external  carotid 
was  re-ligatured  successfully. 

The  remaining  cases  were  treated  by  cold,  astringents,  or  compress. 

[On  a  previous  page  it  is  stated  that  hemorrhage  occurred  in  only 
5  out  of  67  cases  in  which  the  external  carotid  alone  was  tied.] 

COMPARATIVE   SUMMARY  AND  CONCLUSIONS. 

The  rate  of  mortality  after  ligature  of  the  common  carotid  artery, 
as  given  heretofore,  is  41  per  cent. 

After  ligature  of  the  external  carotid  the  death-rate  is  4|  per  cent. 

There  can  be  but  one  conclusion  to  this  comparison.  The  common 
carotid  shoidd  never  he  tied  for  a  lesion  of  the  external  carotid^  or  its 
branches^  when  there  is  room  enough  hetween  the  lesion  and  the  bifurca- 
tion of  the  primitive  carotid  to  permit  the  ligature  of  the  external. 

I  am  led  to  this  conclusion  not  only  by  the  comparison  of  the 
analysis  of  7b9  cases  of  ligature  of  the  common  trunk,  with  the  91 
instances  in  which  the  external  carotid  was  tied,  but  also  from  the 
analysis  of  121  dissections  of  these  vessels,  made  to  determine  the 
relations  of  these  arteries  and  their  branches  to  each  other. 

It  would  be  a  waste  of  time  to  cite  the  eminent  authorities  in 
surgery  who  advise  the  ligature  of  the  co7nmon  trunk  instead  of 
the  external. 

The  teaching  and  practice  is  almost  universal.  It  is  as  wrong  as 
it  is  general.  It  is  as  false  as  it  is  dangerous.  It  is  41  per  centum 
of  deaths  in  the  one,  to  4|  per  centum  in  the  other. 


•  Double  ligature. 

2  Dr.  Peuguet's  case  is  not  included  on  account  of  the  abnormal  arrangement  of  tbe 
Vessels. 


SURGICAL    HISTORY    OF    CAROTID    ARTKRIES. 


135 


Tliis  "History"  carries  its  own  proof  of  the  generality  of  tliis 
practice. 

I  have  selected  out  of  the  statistics  all  the  instances  in  which  the 
common  carotid  was  tied  when  the  external  carotid  might  have  been 
secured  between  its  origin  from  the  common  trunk  and  the  lesion. 

I  have  omitted  all  cases  in  which  raeagreness  of  detail  leaves  the 
least  doLibt  as  to  the  seat  of  lesion,  and  furthermore,  all  the  cases  of 
malignant  growths  of  the  antrum,  where,  owing  to  the  exaggerated 
nutrition  of  the  diseased  structures,  the  anastomosis  had  probably 
been  very  freely  establislied  between  the  ophthalmic  nnd  the  internal 
maxillary,  facial,  and  temporal  arteries,  so  that  ligature  of  the  com- 
mon  trunk  became  the  surest  method  of  "starving  out"  the  disease. 

With  these  numerous  omissions  there  were  251  out  of  a  total  of 
789,  and  of  these  108  died  (or  43  per  cent.). 

[They  are  Nos.  2,  3,  4,  5,  6,  11,  13,  15,  16,  17,  19,  21,  24,  25,  27, 
28,  29,  30,  40,  45,  46,  48,  49,  50,  61,  62,  63,  67,  68,  76,  78,  82,  86, 
87,  88,  91,  92,  94,  99,  102,  103,  116,  123,  124,  132,  133,  134,  137, 
143,  147,  148,  151,  158,  159,  168,  169,  170,  172,  173,  177,  179,  184, 
186,  187,  189,  190,  192,  197,  198,  202,  209,  211,  213,  217,  223,  227, 
232,  234,  237,  239,  240,  241,  246,  249,  250,  252,  254,  257,  261,  263, 
265,  266,  267,  268,  269,  270,  271,  276,  279,  298,  299,  306,  313,  319, 
320,  321,  338,  341,  349,  351,  352,  353,  359,  360,  361,  362,  363,  365, 
368,  370,  371,  374,  378,  380,  381,  382,  384,  386,  388,  391,  393,  397, 
398,  401,  403,  406,  408,  415,  416,  421,  424,  425,  428,  429,  436,  442, 
443,  448,  449,  450,  451,  457,  458,  464,  468,  469,  471,  472,  486,  496, 
498,  510,  512,  513,  519,  520,  525,  528,  533,  534,  535,  541,  546,  551, 
653,  554,  572,  573,  575,  579,  580,  585,  586,  587,  594,  599,  603,  606, 
609,  611,  615,  616,  628,  630,  634,  636,  640,  643,  644,  645,  646,  649, 
656,  657,  658,  663,  664,  667,  668,  671,  672,  673,  674,  677,  678,  679, 
680,  681,  683,  684,  694,  698,  699,  703,  705,  708,  710,  712,  713,  716, 
733,  734,  735,  738,  739,  744,  746,  748,  751,  755,  758,  764,  765,  767, 
768,  772,  773,  786,  788,  789,  in  the  statistics.] 


CONCLUSIONS. 


1.  In  all  intra-cranial  lesions  involving  alone  the  internal  carotid 
or  its  branches,  this  vessel  should  be  tied.  If  this  procedure  is  not 
successful,  then  the  external  carotid  &ho\i\A  be  secured  at  the  crossing 
of  the  digastric.  If  the  fascial  be  given  off  below  this  point,  it  should 
be  secured  by  a  separate  ligature. 

Since  one  of  the  dangerous  results  of  ligature  of  the  common  caro- 


136  PRIZE    ESSAY. 

tidi?,  cerebral  anaemia,  it  is  evident  that  this  danger  will  be  partially 
avoided  bj  leaving  the  anastomotic  channel,  between  the  facial^  in- 
ternal maxillary,  and  temporal  branches  of  the  external  carotid,  and 
the  branches  of  the  oj^hthalmic  from  the  internal  carotid,  uninter- 
rupted. If  this  collateral  current  should,  however,  prove  to  be  an 
impediment  to  a  cure,  it  should  be  stopped. 

For  lesions  of  the  internal  carotid  in  the  neck  (excepting  aneurism) 
it  should  be  tied  alove  and  helow  the  lesion  in  all  cases.  The  opera- 
tion on  the  cardiac  side  alone,  be  the  common  or  internal  trunk  the 
seat  of  the  ligature,  is  not  justifiable,  death  having  occurred  in 
many  instances  through  the  descending  current  from  the  circle  of 
Willis. 

In  aneurism  of  this  artery  the  single  ligature  on  the  cardiac  side 
will  suffice. 

2.  When  the  lesion  (excepting  aneurism)  exists  within  one-half 
inch  of  the  bifurcation  of  the  common  carotid,  involving  this  vessel, 
or  the  external  or  internal  or  both,  the  common  trunk  must  be  tied 
on  the  cardiac  side,  and  the  other  two  arteries  upon  the  distal  side 
of  the  lesion.  The  s^iperior  thyroid  and  any  other  branches  of  the 
external  carotid,  between  the  ligature  upon  this  vessel  and  the  bifur- 
cation, should  also  be  secured. 

In  case  of  aneurism  in  either  of  these  points  the  single  ligature 
on  the  cardiac  side  will  usually  suffice. 

3.  In  erectile  or  pulsating  tumors  of  the  orbit  (intra-orbital  aneu- 
rism) ligature  of  the  common  carotid  is  to  be  advised.  The  vessel 
should  be  secured  at  the  omo-hyoid,  a  double  ligature  applied,  the 
artery  divided  between,  and  each  end  twisted  ("torsion"  of  Bryant). 
If  the  disease  is  malignant  the  entire  contents  of  the  orbital  cavity 
should  be  removed. 

Since  the  anastomoses  between  the  terminal  branches  of  the  ex- 
ter7iala,Y\d  internal  carotids,  through  the  orbit,  are  more  or  less  exag- 
gerated in  intra-orbital  aneurism,  and  since  in  the  52  recorded 
instances  of  this  operation  (in  non-malignant  conditions)  the  death- 
rate  was  only  llj  per  cent.,  I  am  of  the  opinion  that  the  ligature  of 
the  common  carotid  is  the  surest  and  safest  operation. 

If,  however,  the  operation  of  enucleation  be  determined  upon 
(the  eye  being  already  destroyed),  it  may  not  be  necessary  to  tie 
the  common  carotid.  Pressure  upon  the  artery  of  the  affected  side 
will  in  most  cases  control  the  hemorrhage,  until  the  operation  is 
completed,  when  the  compress  in  the  orbit  will  most  probably  con- 
trol the  bleeding ;  the  danger  of  interfering  with  the  intra-cranial 
circulation  being  thus  avoided,  or  deferred  until  the  necessity  exists. 


SURGICAL    HISTORY    OF    CAROTID    ARTERIES.  137 

4.  Wounds  of  the  superior  thyroid  artery,  too  near  its  origin  to 
permit  a  ligature  on  the  cardiac  side  of  the  lesion,  require  deligation 
of  the  common,  external^  and  internal  carotids^  and  torsion  of  the  distal 
end  of  the  wounded  vessel. 

5.  In  incised^  punctured,  lacerated^  and  gunshot  wounds  of  the  ex- 
ternal carotid^  or  its  branches,  where  it  is  deemed  inexpedient  to 
secure  the  vessel  at  the  seat  of  injury,  the  external  carotid  of  one  or 
both  sides  should  be  secured^  below  the  origin  of  the  liri,fju(d  (the  point 
of  election,  see  Anatomy).  If  the  linrjiial  or  any  other  branch  is  in 
immediate  contact  with  the  ligature,  it  (or  they)  should  be  also 
secured. 

The  common  trunk  should  never  be  tied  under  such  circumstances 
except  as  a  last  resort. 

6.  Hemorrhage  of  the  tonsils  and  pharynx,  if  not  arrested  by  liga- 
ture of  the  external  carotid,  as  advised,  will  require  either  the  sepa- 
rate ligature  of  the  pharyngea  ascendens  or  of  the  common  and  inter- 
nal carotids. 

7.  It  must  be  assumed  that  when  ligature  of  the  external  carotid 
below  the  origin  of  the  lingual  does  not  arrest  hemorrhage  from  the 
pharynx,  the  bleeding  is  from  the  ascending  pharyngecd,  and  that 
this  branch  originates  from  the  bifurcation  or  the  internal  carotid. 
(See  Surgical  Anatomy.)  (The  history  gives  one  or  two  deaths 
from  hemorrhage  from  the  tonsils  after  ligature  of  the  common  trunk 
alone.) 

8.  Aneurism  of  the  external  carotid  or  its  branches  (excepting  the 
superior  thyroid)  demands  deligation  of  the  external  carotid  alone, 
when  a  sufficient  space  exists  between  the  tumor  and  the  bifurca- 
tion to  admit  the  ligature  with  safety. 

9.  Aneurism  of  the  internal  carotid  should  be  treated  by  ligature 
of  this  vessel  alone,  when  there  is  sound  artery  enough  between  the 
tumor  and  the  bifurcation  to  admit  the  ligature  with  safety. 

10.  Aneurism  of  the  common  carotid  (if  digital  compression  shall 
have  been  abandoned)  should  be  treated  by  ligature  of  this  vessel 
as  far  from  the  tumor  (on  its  cardiac  side)  as  possible. 

11.  Ligature  of  the  common  carotid  for  aneurism  of  the  arch  of  the 
aorta  is  of  doubtful  propriety.  In  deference  to  the  opinion  of  the 
eminent  surgeons  who  advise  it,  it  may  be  considered  as  sub  judice. 

From  my  own  researches  I  could  not  conscientiously  advise  or 
perform  the  operation. 

12.  Ligature  of  the  common  carotid  alone,  for  the  cure  of  innomi- 
nate aneurism,  is  an  exceedingly  dangerous  procedure  ;  12  of  17  cases 
proved  fatal  from  the  operation.     Only  2  were  cured. 


138  PRIZE     ESSAY. 

I  cannot  justify  the  operation. 

13.  The  common  carotid  and  the  s-nhclavian  artery  were  both  tied 
for  tlie  relief  of  innominate  {comhined  with  aortic  aneurism  in  some 
instances)  amiirism-  in  14  cases.     Died  10. 

This  operation  is  only  justifiable  when  every  more  conservative 
method  sliall  have  been  exhausted.  (See  conclusions  to  History  of 
the  Subclavian,  where  result  of  different  methods  is  given.) 

14.  Ligature  of  the  carotid  artery  alone,  or  with  the  innominate^ 
for  aneurism  of  the  snhclavian  artery  is  not  a  justifiable  procedure. 
Nature  left  to  her  own  resources  is  safer  than  this.  Conservative 
surgery  (see  History  of  Subclavian)  is  superior  to  both. 

15.  In  case  of  aneurism  of  the  carotid  alone,  too  near  the  bifur- 
cation of  the  imnorninate,  or  the  arch  of  the  aorta,  to  permit  the 
ligature  being  placed  on  the  cardiac  side,  the  deligation  of  the  carotid 
on  the  distal  side  would  be  advisable,  provided  the  conservative 
method  o^  direct  (elastic)  pressure  tqion  the  tumor ^  comhined  with  per- 
fect quiet  and  careful  dietetic  treatment,  had  been  previously  and 
persistently  tried  and  had  failed, 

(An  element  of  danger  in  interrupted  pressure  upon  an  aneurismal 
tumor  of  the  carotid  is,  that  particles  of  the  newly  formed  clot  may 
escape  into  the  cranial  circulation.) 

16.  In  epilepsy,  while  the  danger  of  death  as  a  result  of  the  ope- 
ration is  comparatively  slight  (5  per  cent.),  the  proportion  of  cures 
or  improved  cases  is  not  great  enough  to  commend  this  procedure 
to  the  profession. 

(Since  dilatation  of  the  arterials  and  capillaries  of  the  medulla 
oblongata  is  accepted  by  Scliroeder  van  der  Kolk,  Niemeyer^  and 
others  as  the  most  constant  lesion  in  epilepsy,  I  would  suggest,  and 
would  perform  if  the  opportunity  presents,  deligation  of  both  vertebral 
arteries.  This  would  arrest  the  direct  and  probably  irritating  flow 
of  blood  through  this  ganglion,  leaving  the  recurrent  flow  from  the 
carotids  (through  the  posterior  communicating  arteries)  to  supply 
the  necessary  amount  of  nutrition  to  this  portion  of  the  encephalon.) 

17.  In  persistent  and  exhaustive  neuralgiao^  the  fifth  nerve,  when 
all  other  methods  have  proved  ineffectual,  ligature  of  the  common 
carotid  should  be  practised. 

The  external  carotid  of  one  or  both  sides  should  first  be  tied, 
below  the  lingual  (the  point  of  election).  If  this  fails  the  common 
trunk  upon  the  affected  side  may  be  secured. 

The  operation  is  contra-indicated  when  pressure  upon  i\\e  common 
carotid  of  the  affected  side  does  not  arrest  the  pain. 


SURGICAL    PIISTORY    OF    CAROTID    ARTKRIES.  139 

18.  In  liemiplegia  or  li,eadache  the  ligature  of  the  common  carolil  is 
not  justi  liable. 

19.  Ligature  of  both  common  carotids  simultaneously  is  not  justi- 
fiable. 

Ligature  of  both  vessels,  with  an  interval  of  from  oue  week  to  one 
year,  is  not  as  dangerous  as  might  be  expected,  the  danger  being 
less  as  the  interval  is  greater. 

When  the  importance  of  tyiwj  the  external  carotid  for  all  lesions  of 
the  regions  to  which  it  is  distributed  is  fully  apjweciated  and  prcLctlsed 
by  surgeons,  the  double  ligature  of  the  pri)nitive  carotids  will  probabl/j 
not  appear  in  the  future  records  of  surgery ;  while  ligature  of  the  com- 
mon carotid,  with  its  startling  mortality  of  4:1  i^er  cent.,  will  be  confined 
to  tJtose  emergencies  in  laliicli  it  alone  is  involved. 


Fig.  1. 


Aiitoridi-  and  posterior  tomporalin. 


Aiiricularis. 


Occipitalis.     ~ 


Phavyngea  ascendPns. 


The  relation  of  the  brauches  of  the  external  carotid  to  each  other  (the  average 
of  121  dissections).      (Life  size.) 


Fig.  2. 


Showing  range  of  origin  of  the  thyroidea,  lingualis,  and  pharyngea  ascendens. 

(Life  size.) 


Fig.  3. 


Showing  range  of  origin  of  the  occipitalis  and  naaxillaris  externa.     (Life  size.) 


Fig.  4. 


Showing  range  of  ovigiu  of  auricularis  and  range  of  length  of  the  external  carotid. 

(Life  size.) 


Fig.  5. 


Fig.  6. 


Fig.  7. 


The  lingual  and  facial, 
from  a  commou  trunk. 
(31  in  121.)     (Life  size.) 


The  thyroid,  lingual,  and 
facial,  from  a  common 
trunk.     (2  in  121.) 
(Life  size.) 


Showing  the  dangerous 
relation  of  the  first 
five  branches  of  the 
external  carotid  to 

each  other.     (Life  size.) 


Fig. 

Middle  meningeal. 


Temporal, 


Auricular. 


Ascending  pharyngeal. 
Occipital. 


Facial. 


Internal  maxillary. 


^ Superior  thyroid  of  man 

witli  goitre. 


An  unusual  arrangement.     (Full  size.) 


FiGi.  9. 


Relation  of  the  veius  to  the  carotids.      (Life  size.) 


SURGICAL  ANATOMY  AND  OPERATIVE  SURGERY 

OF  THE 

INNOMINATE  AND  SUBCLAVIAN  ARTERIES  AND 
THEIR  BRANCHES. 


THE   ARCH   OF   THE  AORTA,  AND   ITS  RELA'IIONS  TO  THE  .SUR- 
GICAL ANATOMY  AND  OPERATIVE  SURGERY  OF  THE  NECK. 

While  that  portion  of  the  arteria  magna  leading  directly  from 
the  heart  is  usually  described  as  the  arch  of  the  aorta,  it  is  not  usual 
for  it  to  form  one  continuous  and  unbroken  curve,  but  to  consist 
of  three  segments  of  circles  joined  together,  each  differing  from  the 
other  in  the  length  and  intensity  of  its  curvature. 

THE   ASCENDING   SEGMENT. 

This  portion  commences  at  the  most  inferior  surface  of  the  semi- 
lunar valves;  in  the  great  majority  of  subjects  opposite  to  and  be- 
hind the  left  edge  of  the  sternum^  and  about  half  way  between  the 
costo-sternal  articulations  of  the  third  and  fourth  ribs,  this  point 
(that  is  the  centre  of  the  aortic  valves)  being  usually  on  a  level 
with  the  junction  of  the  sixth  and  seventh  dorsal  vertebras  {at  the 
end  of  expiration)  and  about  one  inch  and  a  half  from  the  internal 
surface  of  the  sternum.  From  this  point  the  aorta  travels  obliquely 
upward  and  to  the  right,  a  distance  varying  from  two  to  three  inches, 
and  terminates  in  the  transverse  segment  near  the  right  border  of 
the  sternum,  and  the  costo-sternal  articulation  of  the  right  second  rib. 

If  a  subject  (who  has  died  from  other  than  lesions  of  the  thoracic 
viscera)  be  taken,  the  left  ventricle  laid  open  in  situ,  and  a  straight 
probe  passed  into  the  aorta  and  pushed  directly  in  the  axis  of  the 
ventricle,  the  end  of  the  instrument  will  be  seen  to  impinge  upon 
the  convex  surface  of  the  aorta  at  the  point  where  the  ascending 
joins  with  the  transverse  segment.  At  this  point  is  situated  the 
bulging  known  as  the  sinus  magnus,  and  here  is  the  surface  upon 

(141) 


142  PRIZE    ESSAY. 

which  the  column  of  blood,  driven  bj  the  systole  of  the  ventricle, 
impinges  with  the  greatest  violence,  accounting  for  the  clinical  fact 
that  atheromatous  degenerations  and  aneurismal  dilatations  are  most 
frequently  seated  at  the  junction  of  these  two  segments.  It  is  evi- 
dent that  no  exact  spot  can  be  selected  as  in  the  actual  axis  of  the 
left  ventricle,  since  this  axis  is  shifting  in  the  rotation  of  the  heart 
from  left  to  right  and  from  hehind  forwards  xoith  each  systole,  yet  the 
weak  point  is  near  the  place  represented  by  the  arrow  point  [a)  in 
Fig.  1.  The  semilunar  valves^  the  sinuses  of  Valsalva^  the  coronary 
arteries^  and  the  constriction  at  the  bases  of  the  valves  are  the  points  of 
interest  in  connection  witli  the  first  portion  of  the  aortic  arch.  In 
a  number  of  measurements  of  the  ascending  segment,  made  after  the 
vessel  was  fully  distended  with  injection  matter,  the  average  cir- 
cumference around  the  sinuses  of  Valsalva  was  four  inches;  the 
constriction  just  above,  three  and  one-fourth  to  three  and  one-half 
inches;  while  at  a  point  two  inches  from  the  ventricle  the  circum- 
ference is  greater  than  that  of  the  sinuses. 

As  to  the  valves,  I  found  the  anterior  to  be  largest,  the  left  pos- 
terior next,  and  the  right  posterior  smallest. 

It  is  not  usual  for  any  branches  other  than  the  coronary  arteries 
to  be  given  off  from  this  portion  of  the  aorta.  In  twenty-five  con- 
secutive examinations  as  to  this  feature,  there  were  found  no  anoma- 
lous branches,  yet,  in  a  capacity  where  I  have  examined  a  great 
many  subjects  in  connection  with  demonstrations  of  the  thorax, 
I  have  in  several  instances  observed  small  abnormal  branches 
originating  here. 

Of  the  coronary  arteries^  the  right  comes  from  the  sinus  of  the  an- 
terior valve,  usually  within  (^.  e.  below)  the  edge  of  the  semilunar 
fold,  and,  when  the  blood  is  rushing  through  the  aorta,  after  the 
systole,  the  mouth  of  the  artery  is  occluded  by  the  valve.  The  left 
coronary  is  from  the  anterior  aspect  of  the  left  posterior  valve,  and 
usually  within  the  sinus.  It  follows,  from  the  unique  situation  of 
tliese  two  vessels,  that  they  do  not  pulsate  with  the  heart's  systole, 
and  that  they  are  only  filled  with  blood,  (1)  by  gravity,  when  in  the 
upright  position  ;  (2)  by  the  expansion  of  the  heart  muscle  in  dias- 
tole ;  (b)  and  principally  by  the  contraction  of  the  elastic  aorta.  The 
presence  of  these  arteries  accounts  for  the  larger  development  of 
the  two  valves  with  which  they  are  associated.  It  can  be  readily 
imagined  that  when  the  heart  is  contracting,  the  blood  is  squeezed 
out  of  both  veins  and  arteries  in  its  walls,  and  that  the  last  few 
drops  would  remain  in  the  sinuses  connected  with  the  two  coronary 


INNOMINATE    AND    SUBCLAVIAN    AliTKlifKS,  1J3 

arteries.  This  pressure,  iiowever  little  it  may  be,  would  serve  to 
precipitate  the  closure  of  these  two  valves  before  the  otlier  (the  I'ight 
posterior),  hence  their  development  larger  than  the  one  having  no 
coronary  2)7'essure  exerted  against  it. 

The  constriction  at  the  bases  of  the  semilunar  valves  is  caused  by 
the  aggregation  of  white  fibrous  tissue  at  this  point  greatly  in  ex- 
cess of  the  elastic  fibres  found  in  all  other  portions  of  the  aorta. 

The  function  of  this  fibrous  band  is  to  prevent  dilatation  of  the 
aortic  orifice  and  consequent  regurgitation  of  blood  after  the  systole 
is  complete.  I  have  not  been  able  to  measure  the  amount  of  pres- 
sure sufficient  to  rupture  the  aorta  here,  as,  in  the  various  experi- 
ments made,  tlie  valves  would  either  yield  or  the  pressure  would  be 
relieved  by  rupture  of  the  artery  beyond  this  point. 

THE  SECOND  SEGMENT. 

This,  the  transverse  portion  of  the  aorta,  varies  in  length  from 
three  to  four  inches  in  different  subjects,  and  extends  from  near  the 
costo-sternal  articulation  of  the  right  second  rib,  obliquely  to  the  left 
and  backward,  until  in  the  neighborhood  of  the  upper  portion  of 
the  third  dorsal  vertebra  it  turns  quite  abruptly  downward  as  tlje 
descending  portion.  From  the  convexity  of  the  second  segment,  a 
little  anterior  to  its  middle  line  (as  looked  at  from  above),  arise  in 
quick  succession  the  three  great  vessels — the  innominate^  left  carotid^ 
and  subclavian  arteries. 

The  arteria  innominata,  usually  the  first  branch  (larger  in  itself 
than  the  combined  calibres  of  the  left  carotid  and  sichclavian),  comes 
off'  in  the  majority  of  subjects  itnmediately  in  front  of  the  trachea, 
just  behind  the  middle  of  the  sternum,  at  a  level  varying  from  one- 
half  to  one  and  one-half  inch  below  the  upper  margin  of  the  manu- 
brium. (It  is  exceedingly  rare  for  the  arch  of  the  aorta  to  be  found 
above  or  below  the  points  above  indicated.) 

From  this  origin  the  innominata  travels  obliquely  upward,  back- 
ward, and  to  the  right  (crossing  the  trachea  from  its  centre),  and 
bifurcates,  near  the  upper  margin  of  the  clavicle,  between  the  sternal 
and  clavicular  origins  of  the  sterno-mastoideus  into  the  carotid  and 
stibclavian  arteries,  the  first  of  these  coming  from  its  anterior  aspect, 
the  last  a  direct  continuation  of  the  arch  of  the  innominate.  (The 
innominata  in  rare  instances  originates  to  the  left  of  the  trachea, 
more  frequently  it  is  given  off  before  it  reaches  the  windpipe.) 
The  following  Table  (I)  gives  a  synopsis  of  28  consecutive  measure- 


144  PRIZE    ESSAY. 

ments  to  obtain  the  average  distance  of  the  centre  of  origin  of  this 
artery  from  the  most  dependent  portion  of  the  semilunar  valves 
{i.  e.  the  commencement  of  the  aorta). 

TABLE   I. 

Showing'  length  of  aorta  from  most  dependent  portion  of  the  semilunar  valves  to 
centre  of  origin  of  the  arteria  innominata.  (JVIeasurements  made  along  the 
centre  of  the  arch.) 


No. 

Males. 

1 

3|in 

iches, 

2 

3i 

3 

H 

4 

H 

5 

H 

6 

3 

7 

H 

8  , 

3i 

9 

3i 

10 

4 

11 

31 

No. 

Females. 

1 

H 

Inches, 

2 

4 

3 

3i 

4 

H 

5 

3 

6 

3i 

T 

H 

8 

n 

9 

H 

.0 

3i 

STo. 

Sex  not 

noted. 

1 

u 

inches. 

2 

4 

.( 

3 

3f 

(( 

4 

4 

(( 

5 

3| 

i( 

6 

3* 

u 

11         3         " 
Total  number  28.     Total  of  measurements,  97.50  inches. 

Average  distance  of  centre  of  origin  of  arteria  innominata  from  most  depend- 
ent portion  of  semilunar  valves  =  3.48  +  inches. 

It  will  be  seen,  that,  while  it  varies  between  3  and  4  inches,  the 
average  distance  is  3.48-1-  inches,  this  origin  being  in  the  majority 
of  cases  one  inch  below  the  upper  margin  of  the  manubrium. 

In  table  (II.)  is  given  the  result  of  37  consecutive  measurements 
of  the  length  of  the  innominata.  The  shortest  instance  is  f  inch, 
the  longest  2  inches,  the  average  1.51 -f  inch. 

*  TABLE   II. 

Showing  the  result  of  37  measurements  of  the  arteria  innominata. 


No. 

Males. 

No. 

Females. 

No. 

Sex  not 

noted. 

1 

Ix  inches. 

1 

If 

inches. 

1 

H 

inches. 

2 

li 

2 

H 

u 

2 

3 

H 

3 

2 

u 

3 

If 

4 

li 

4 

If 

(i 

4 

2 

5 

H 

5 

If 

u 

5 

1^ 

6 

U 

6 

u 

u 

6 

1 

7 

u 

7 

li 

u 

7 

1 

8 

Ij 

8 

H 

u 

8 

If 

9 

li 

9 

i| 

u 

9 

1| 

10 

1 

10 

2 

u 

10 

u 

11 

li 

11 

u 

u 

11 

^4 

12 

2 

12 

li 

u 

13 

u 

13 

li 

u 

Total  No.  =  37.  Total  length  =  56.12  4-  inches.  Average  length  =  1.51 -f- 
inches. 

In  5  of  34  cases  this  vessel  gave  origin  to  abnormal  branches.  In  the  three  cases 
where  the  thyroidea  inferior  was  derived  from  the  arteria  innominata,  there  was 
no  thyroid  branch  from  the  axis  of  this  name. 


INNOMINATE    AND    RUBCLAVIAX    AllTKIUKB.  145 

The  presence  of  abnormal  branches  from  the  innominate  will  be 
again  referred  to  in  the  "Surgical  History"  of  this  vessel.' 

The  left  common  carotid  originates,  on  an  average.  3.02  inches 
distant  from  the  commencement  of  the  aorta,  and,  as  shown  in  the 
following  Table  III.,  its  centre  of  origin  is  .43+  inch  from  that 
of  the  innominate.  In  6  of  31  cases  I  have  marked  it  as  com- 
mon with  the  innominate.  I  do  not  mean  that  in  1  of  5  cases 
it  will  be  found  to  come  off  from  this  last  vessel,  without  being 
in  intimate  relation  with  the  arch  of  the  aorta,  but  that  in  this 
proportion  of  cases  they  are  so  intimately  associated  in  their 
origins  that,  while  their  outer  walls  originate  from  the  arch.^  their 
inner  or  adjacent  walls  are  fused  together,  and  this  septum  does  not 
extend  to  the  level  of  the  aortic  curve,  being  removed  upward  from 
I  to  I  inch. 

TABLE   III. 

Showing  the  distance  betweeu  the  centres  of  origin  of  arteria  innominata  and 

carotis  sinistra. 


No. 

Males. 

No. 

F 

emales 

No. 

Sex  not  noted. 

1 

1  inch. 

I 

1 

inch. 

1 

^  inch. 

2 

Common. 

2 

c. 

ommon. 

2 

i     " 

3 

^  inch. 

3 

(( 

3 

Common. 

4 

3        U 
4 

4 

i 

inch. 

4 

^  inch. 

5 

2 

5 

c 

ommon. 

5 

2 

6 

i    " 

6 

3 

4 

inch. 

T 

Common. 

7 

1 
2 

u 

8 

\  inch. 

8 

2 

u 

9 

2 

9 

1 
2 

u 

10 

3        (( 

10 

i. 
2 

u 

11 

1        " 

11 

2 

a 

12 

1         U 
2 

12 

1 

2 

(( 

13 

1.       » 
9 

13 

a 

Total  No.  =  31.     Total  length  =  13.37  inches.     Average  =  .43 -|-  inch. 

The  left  subclavian  artery^  the  second  in  size  of  the  three  great 
vessels  coming  from  the  arch  of  the  aorta,  arises  to  the  left  of  and 
(as  looked  at  in  situ  from  the  front)  somewhat  behind  the  preceding 
vessel.  Its  distance  from  the  commencement  of  the  arteria  magna 
and  its  relation  to  the  carotid  will  be  seen  in  Table  IV. 

'  See  Surgical  Anatomy  of  the  right  thyroid  axis,  and  Fig.  3,  for  arrangeiuent  of 
anomalous  branches  of  the  iunominate. 

10 


146  PETZE    ESSAY.    • 

TABLE   lY. 

Showing  the  distance  between  the  centres  of  origin  of  the  carotis  and  suhdavia 
sinistra,  and  the  distance  of  the  latter  from  the  commencement  of  the  aorta. 


Jfo. 

Males. 

1 

i 

2 

inch, 

2 

3 

4 

3 

1 
2 

4 

1 

5 

3 
4 

6 

1 

t 

3 

4 

8 

1 

9 

3 
4 

10 

1 

11 

3 

4 

12 

i 

13 

1 

" 

No. 

Females. 

1 

li 

inch. 

2 

1 

(( 

3 

3 
4 

(( 

4 

1 

(( 

5 

3 

4 

u 

6 

1 

u 

7 

3 

4 

u 

8 

1 

u 

9 

1 

u 

10 

f 

u 

11 

1 

u 

12 

3 

4 

(( 

13 

3 

4. 

(( 

No. 

Sex 

not  noted. 

1 

3 

4 

inch. 

2 

u 

3 

1 

i; 

•4 

1 

u 

5 

1 

(( 

6 

f 

u 

7 

3 

4 

(( 

8 

1 

(( 

9 

3 

4 

u 

Total  No.  =  35.  Total  length  :=  27.75  inches.  Average  =  .79-f-,  or  about 
four-fifths  of  one  inch. 

'I'his  gives  the  distance  from  the  beginning  of  the  aorta  to  the  centre  of  origin  of 
the  suhdavia  sinistra  as  a  little  less  than  four  and  four-fifths  inches. 

The  average  distance  of  the  centre  of  origin  of  the  suhclavian 
being  .79 -H  inch  from  the  carotid,  and  4,72  inches  from  the  com- 
mencement of  the  aorta. 

The  descending  segment,  or  the  third  portion  of  the  arch,  begins 
from  I  to  1  inch  beyond  the  origin  of  this  last  artery,  when  the 
aorta  turns  sharply  downward  near  the  upper  border  of  the  third 
dorsal  vertebra,  and  is  continuous  as  the  thoracic  aorta  beyond  the 
body  of  the  fourth  dorsal  vertebra. 

The  Arch  of  the  Aorta  as  a  Whole. 
In  Fig.  1,  I  have  sketched  roughly,  yet  accurately,  the  life  size 
and  average  arrangement  of  the  aortic  arch  and  the  great  vessels 
coming  from  it.  It  has  already  been  stated  in  connection  with  the 
first  portion  why  the  junction  of  this  with  the  second  portion  should 
be  the  seat  of  lesions  demanding  the  interference  of  the  surgeon.^ 
The  situation  of  the  innominate  just  beyond  this  weak  point,  and  in 
direct  range  of  the  blood  pressure  that  is  bearing  upon  the  roof  of 
the  arch,  will  also  explain  why  this  vessel  is  involved  in  lesions, 
next  in  frequency  to,  and  almost  always  in  connection  with,  the 
lesions  of  the  ascending-transverse  junction.  The  position  of  the 
left  carotid  brings  it  next  in  order,  being  often  involved  with  the 

•  See  Resume  of  Surgical  History. 


INNOMINATE    AND    SUBCLAVIAN    AUTKRTKS,  147 

innominate;  while  the  origin  and  direction  of  the  left  suhclavian  ex- 
plain why  it  is  rarely  the  seat  of  aneurisrnal  disease.  Tn  a  number 
of  cases  in  which  I  measured  the  angles  of  incidence  and  reflection, 
from  the  point  a,  Fig.  1,  I  found  that  the  line  of  reflection  im- 
pinged upon  the  arch  of  the  aorta  beyond  the  mouth  of  the  left  suh- 
clavian. While  this  law  of  equality  of  the  angles  of  incidence  and 
reflection  is  not  practicably  applicable  to  the  movements  of  liquids 
(nor  to  the  aortic  arch,  which  is  an  elastic  and  fluctuating  cylinder), 
yet  a  glance  at  the  direction  of  the  axis  of  the  left  subclavian  (at 
almost  a  right  angle  to  the  axis  of  the  arch),  will  explain  the  im- 
munity of  this  vessel  from  lesions  resulting  from  pressure,  as  com- 
pared with  the  vessels  heretofore  named,  and  as  compared  with  the 
descending  portion  of  the  arch  just  beyond,  upon  which  the  blood 
current  must  impinge  with  more  force.  Clinical  facts  are  in  accord 
with  this  explanation,  based  upon  the  anatomical  relations.  Of 
less  interest  to  the  surgeon,  perhaps,  is  the  occasional  interference 
with  the  circulation  in  the  coronary  arteries  by  adhesions  of  the  semi- 
lunar valves  to  the  sides  of  the  sinuses  of  Valsalva  in  some  instances 
of  aortic  resfurffitation. 

The  largest  portion  of  the  aorta  is  at  the  sinus  magnus  (see  Fig. 
1),  and  the  diminution  in  the  calibre  of  the  third  segment  is  not  in 
proportion  to  the  combined  calibres  of  the  three  great  trunks  given 
off  from  the  second  segment. 

In  3  of  20  cases  examined  as  to  this  feature,  small  abnormal 
arteries  were  derived  from  the  anterior  aspect  of  the  transverse 
segment. 

THE    SURGICAL   ANATOMY   OF   THE   SUBCLAVIAN   ARTERIES. 

In  order  to  arrive  at  results  as  positive  as  possible,  I  selected  13 
male  and  13  female  subjects  just  as  they  were  brought  to  the  dis- 
secting rooms,  and  the  fifty-two  dissections  given  hereafter  are  from 
these  subjects. . 

The  right  subclavian.^  larger,  shorter,  and  more  superficial  at  its 
origin  than  the  left,  is  derived  from  the  innominate  behind  the  origin 
of  the  carotid,  about  the  level  of  the  upper  margin  of  the  clavicle 
(more  frequently  above  than  below  this  line),  behind  the  interval 
between  the  two  tendons  of  the  sierno-mastoideus.  It  is  the  direct 
continuation  backward,  upward,  and  outward  of  the  arch  of  the  in- 
nominate, and  is  continuous  with  the  axillary  artery,  at  the  lower 
edge  of  the  first  rib. 

The  left  subclavian,  derived  1.23  inch  beyond,  to  the  left  of,  and 
more  deeply  situated  in  the  thorax  than,  the  innominate,  travels 


148 


PRIZE    ESSAY, 


almost  vertically  upwards,  until  it  mounts  above  the  upper  surface 
of  the  first  rib,  when  it  curves  very  abruptly  outward  and  down- 
ward, passing  behind  the  scalenus  anticus  and  thence  to  the  lower 
edge  of  the  first  rib.  The  comparative  length  of  the  two  sub- 
clavians  is  shown  in  the — 

TABLE 

Of  measurements  of  twenty-six  subjects,  as  to  the  length  of  the  subclavia  dextra 
and  sinistra.     (The  length  of  the  innominata  appended.) 


FEMALES. 

MALES. 

No. 

Left  Sub. 

Righ 

t  Sub. 

Innom. 

No. 

Left  Sub. 

Righ 

t  Sub. 

Innom. 

1 

^ 

inches. 

3 

nches. 

H 

inch. 

14 

31 

inches. 

2|i 

nches. 

11  incl 

2 

H 

2| 

u 

If 

(( 

15 

3| 

u 

2| 

u 

If    " 

3 

3| 

3f 

u 

2 

16 

31 

a 

92 

u 

1 X  u 
••2 

4 

3f 

96 

(( 

If 

17 

31 

u 

2| 

(( 

1 1      'i 

^2 

5 

4f 

3 

a 

If 

18 

4 

u 

21 

u 

^2 

6 

3f 

3 

u 

H 

19 

4^ 

(( 

3| 

u 

^2 

n 

3* 

2| 

u 

H 

20 

31 

u 

21 

u 

U    " 

8 

2| 

2* 

u 

H 

21 

2| 

u 

2* 

li 

n  " 

9 

3| 

2-1 

u 

n 

22 

31 

u 

2f 

u 

U    " 

10 

4f 

3| 

u 

2 

23 

4| 

(( 

2f 

ii 

li  - 

11 

4| 

4 

li 

H 

24 

4f 

it 

3| 

a 

1    " 

12 

4 

02 

a 

H 

25 

4| 

kl 

3 

a 

2    " 

13 

H 

op. 

u 

H 

26 

H 

u 

n 

u 

IJL  u 
^2 

As  shown  b}'  these  figures  the  average  length  of  the  7^iyht  sub- 
clavian is  2.83  inches;  of  the  left  3.74  inches.  The  average  length 
of  the  innominate  in  these  26  instances  is  the  same  as  that  given  in 
the  table  of  37  cases  on  a  previous  page,  ^.  e.  1.51+  inch.^  The 
length  of  the  right  subclavian  plus  the  innominate  is  .60  inch  more 
than  the  left,  since  this  last  vessel  is  given  off  well  to  the  left  of  the 
median  line. 

Each  subclavian  may  be  said  to  have  three  surgical  divisions.  The 
first  division  of  the  right  artery  is  from  its  origin  from  the  innoini- 
nate  to  the  inner  border  of  the  scalenus  anticus.  That  of  the  left 
artery,  from  its  origin  at  the  arch  of  the  aorta  to  the  inner  border 
of  the  left  scalenus  anticus. 

The  second  and  third  portions  of  both  vessels  are  identical  as  re- 
gards direction  and  relation,  being  different  in  the  origins  of  their 
respective  branches.  The  second  surgical  division  of  each  is  entirely 
to  the  inner  side  of  the  inner  border  of  the  first  rib.  The  third  2^or- 
Hon,  resting  chiefly  on  the  upper  surface  of  the  first  rib,  is  in  many 


'  The  innominate  is  somewhat  lonster  in  females  than  in  males. 


INNOMINATE    AND    SUBCLAVIAN    ARTEHIES. 


149 


instances  partly  within  tlic  inner  margin  of  tlio  rib,  owing  to  tlie 
obliquity  of  the  scalenus  anticus  as  it  passes  downward  and  out- 
ward to  be  attached  to  the  inner  margin  of  this  bone.  The  follow- 
ing tables  give  tlie  average  lengths  of  the  various  divisions  of  these 
two  arteries. 

TABLE. 
Suhdavia  dcxtra — Length  of  its  three  surgical  divisions. 


MALES. 

FEMALES. 

No. 

1st  Div. 

2d  Div. 

3d 

Div. 

No. 

l8t  Div. 

2d  Div. 

3d 

Div. 

1 

1 

inch. 

1 
2 

inch. 

U 

inch. 

1 

li 

inch. 

^  inch. 

1 

lllcll 

2 

H 

a 

f 

(( 

H 

u 

2 

1 

f 

U 

u 

3 

H 

u 

2 

u 

1 

u 

3 

ll 

3 

4 

li 

a 

4 

f 

a 

1. 
2 

(( 

1 

a 

4 

u 

1. 
2 

U 

u 

5 

1 

u 

5 

8 

a 

i 

14 

5 

1 

i. 

2 

1 

u 

6 

1 

u 

1 

2 

u 

1 

u 

6 

8 

2 

3 
4 

u 

1 

H 

u 

1 

(( 

H 

u 

Y 

li 

1 

2 

1 

a 

8 

n 

u 

i 

u 

1 

u 

8 

li 

5 

8 

u 

i( 

9 

1 

u 

1 

u 

H 

u 

9 

li 

2 

li 

u 

10 

1 

u 

1 

2 

u 

I 

u 

10 

1t\ 

1 
2 

IxV" 

11 

H 

u 

1 

2 

u 

I 

u 

11 

1 

1 

li 

(( 

12 

H 

u 

1 

2 

u 

7 
8 

u 

12 

li 

1 

2 

li 

u 

13 

1 

u 

i 
2 

(( 

1 

u 

13 
Tot'l, 

U 

1 
2 

- 

li 

(( 

Total 

,14.6 

t.37 

13. 

25 

15.31 

7.62 

15.5 

6 

Suhdavia  sinistra 
MALES. 


TABLE. 

—Length  of  its  three  surgical  divisions. 
FEMALES. 


Total,  27.50 


7.25 


13.37 


No. 

1st  Div. 

2d  Div. 

3d 

Div. 

No. 

Is 

t  Div. 

2d  Div. 

3d  Div. 

1 

2f 

inches. 

2 

inch. 

u 

inch. 

1 

2 

inches. 

1 
9 

inch. 

1     incll 

2 

n 

u 

1 

u 

li 

u 

2 

If 

u 

1 

u 

u 

u 

3 

3 

u 

2 

(( 

1 

u 

3 

2f 

u 

f 

u 

u 

u 

4 

ll 

u 

1 
2 

u 

1 

u 

4 

2| 

(( 

JL 

2 

u 

li 

u 

5 

If 

u 

f 

u 

1 

2 

u 

5 

If 

(i 

i 

u 

1 

u 

6 

2 

(( 

1 
2 

u 

3 
4 

(( 

6 

li 

u 

1 

2 

u 

4 

(( 

7 

n 

l( 

1 

u 

U 

u 

7 

If 

u 

3 

4 

(( 

1 

u 

8 

H 

u 

2 

u 

1 

u 

8 

If 

u 

5 

8 

u 

li 

u 

9 

2i 

u 

1 
2 

u 

li 

u 

9 

2i 

u 

i 

u 

If 

u 

10 

1| 

(( 

i 

a 

1 
8 

u 

10 

2 

u 

8 

u 

li 

u 

11 

2i 

(( 

i 

2 

u 

1 

u 

11 

1| 

(( 

3 

4 

u 

li 

lli 

12 

2 

u 

1 
2 

u 

f 

a 

12 

2i 

u 

i 

u 

n 

u 

13 

H 

u 

5 

8 

u 

1 

(( 

13 

2i 

u 

i 

u 

n 

li 

Total,    26.12  7.50 


15.62 


150  PRIZE    ESSAY. 

While  the  first  portion  of  the  right  subclavian  varied  in  26  cases 
from  f  to  1|-  inch  in  length,  the  average  length  was  1.154-  inch 
(being. a  little  greater  in  females  than  in  males). 

The ^rs^  .portion  of  the  left  artery  varied  from  IJ  to  8  inches,  the 
average  length  being  2.06+  inches  (or  in  males  2.11  inches,  in 
females  2.01). 

The  second  portion  of  the  right  subclavian  averaged  .58 — inch; 
the  same  division  of  the  left  subclavian  being  .56+  inch  in  length. 
(This  slight  diiierence  may  possibly  be  accounted  for  in  the  develop- 
ment of  the  right  muscle  more  than  the  left.) 

The  tJiird portion  o^  i\\Q  right  artery  is  a  little  less;  the  same  divi- 
sion of  the  left  subclavian  a  little  more  than  1.11  inch  in  length. 

SURGICAL  BRANCHES  OF  THE  SUBCLAVIAN  ARTERIES. 

Nine  important  arteries  arise  directly  or  indirectly  from  the  sub- 
clavian arteries;  the  vertebral^  ijiternal  mammary,  transversalis  colli, 
suprascapular,  inferior  thyroid,  cervicalis  ascendens,  superior  iritercostal, 
profunda  cervicis,  Sixid  posterior  scapular. 

Upon  the  right  side  the  vertebral  was  derived  from  the  1st  divi- 
sion of  the  subclavian  in  every  one  of  26  consecutive  cases.  It 
arises  from  the  superior  and  posterior  aspect  of  the  main  trunk,  and' 
passes  upward  to  the  vertebral  foramen  in  the  6th  cervical  vertebra 
(often  to  the  5th,  less  often  to  the  4th).  As  the  relation  of  this 
vessel  to  the  bifurcation  of  the  innominate  is  considered  a  point  of 
no  little  importance  in  the  ligature  of  the  first  division  of  the  sub- 
clavian, I  have  given  in  Fig.  2  the  range  of  origin  of  the  vertebral. 
Radiating  from  Y,  the  lines  show  that,  while  this  branch  may  range 
from  f  of  an  inch  to  1 J  inch  distant  from  the  innominate,  4  per  cent, 
will  be  found  between  J  and  f  of  an  inch,  87  per  cent,  between  |  and 
1  inch,  and  8  per  cent,  between  1  and  1|  inch  from  the  origin  of 
the  subclavian.  I  give  below  the  exact  parts  of' an  inch  in  which 
this  vessel  was  in  20  cases  removed  from  the  bifurcation: — 

10  males,  f,  |,  J,  f,  1,  1,  |,  |,  |,  |;  average  .75  inch. 

10  females,  f,  |,  |,  f,  |,  |,  |,  1^,  1|,  |;  average  .81  inch. 

Average  distance  of  all  cases  .78  inch. 

Since  the  average  length  of  the  1st  division  on  this  side  is  1.15  + 
inch,  the  origin  of  the  vertebral  will  be  .37  inch  (or  about  ^  of  an 
inch)  to  the  inner  side  of  the  inner  border  of  the  scalenus  anticus. 
It  should  be  looked  for  and  secured  without  exception  in  ligature 
of  this  division  of  the  main  trunk.     (See  Surgical  History.) 


INNOMINATE    AND    SUBCLAVIAN    AKTKUIKS.  151 

The  left  vertebral  w^s  derived  from  the  1st  division  of  the  sub- 
clavian in  24  of  the  26  cases,  and  in  23  of  these  24  it  was  given  off 
(as  represented  in  Fig.  1)  just  where  the  subchivian  bends  so  ab- 
ruptly to  the  left  in  arching  over  the  first  rib.  It  is  thus  almost  a 
direct  continuation  of  the  axis  of  the  main  trunk,  a  fact  which 
accounts,  as  I  believe,  for  the  larger  size  of  the  left  vertebral  as 
compared  with  the  right,  which  is  derived  from  the  main  trunk  at 
a  rifjht  angle  to  the  blood  current,  and  is  thus  unfavorably  situated. 
In  22  cases  examined  the  left  was  larger  in  12,  they  were  equal  in 
diameter  in  5,  the  right  the  larger  in  5  instances.'  (See  Fig.  2.) 
8  per  cent,  originate  from  the  aortic  arch  close  to  the  subclavian, 
12  per  cent,  within  If  inch  from  the  aorta,  and  80  per  cent,  between 
If  and  2|  inches.  In  2  of  26  cases  it  was  from  the  aorta,  by  the 
side  of  the  main  trunk.  Ligature  of  the  vertebral  should  be  prac- 
tised in  ligature  of  the  subclavian  within  the  scalenus,  though  it  is 
a  more  formidable  operation  on  account  of  the  dangerous  prox- 
imity of  the  thoracic  duct.  It  can  be  most  safely  reached  in  the  5th 
intervertebral  space. 

The  internal  mammary  artery  is  the  most  regular  in  its  origin  of 
all  the  branches  given  off  from  the  subclavian.  Arising  from  the 
anterior  and  inferior  aspect  of  this  vessel  just  to  the  inner  side  of 
the  inner  border  of  the  scalenus,  it  passes  downward  (a  little  inward 
at  first)  behind  the  costal  cartilages,  parallel  with  the  edge  of  the 
sternum  and  from  \  to  f  of  an  inch  distant  from  it.  In  47  of  52 
cases  this  branch  was  from  the  first  portion  of  the  main  trunk,  in  3 
of  52  from  the  thyroid  axis  (twice  on  the  right  side),  and  in  the  re- 
maining 2  of  52  cases  it  was  from  the  second  division  of  the  sub- 
clavian^ just  behind  the  scalenus  near  its  inner  border.  (This  last 
anomalous  origin  was  on  both  sides  of  the  same  subject.)  The 
phrenic  nerve  is  intimately  associated  with  the  origin  of  the  internal 
mammary.  In  21  cases  examined  as  to  this  feature,  the  nerve 
crossed  in  front  of  the  artery  in  17,  and  behind  it  in  4  instances. 
In  Fig.  2  the  lines  radiating  from  I  M  indicate  the  range  of  origin 
of  this  branch,  being  in  90  per  cent,  of  cases  within  \  of  an  inch  of 
the  inner  edge  of  the  scalenus  on  the  right  side  and  not  varying 
more  than  J  inch  to  the  inner  border  of  this  muscle  on  both  sides 
in  52  cases  (a  regularity  of  arrangement  exceedingly  rare  in  human 
anatomy).  As  shown  in  Fig.  1,  its  origin  is  in  the  majority  of 
cases  intimately  associated  with  that  of  the  thyroid  axis. 

•  Hyitl  says  all  of  the  branches  of  the  right  subclavian  are  larger  than  those  of 
the  left.     With  the  above  exception  this  is  correct. 


152  PRIZE    ESSAY. 

The  thyroid  axis  is  derived  from  the  anterior  superior  aspect  of 
the  subclavian  just  at  the  inner  margin  of  the  anterior  scalenus. 
In  most  subjects  this  axis  is  about  J  inch  long,  and  gives  origin 
to  the  inferior  thyroid,  transversalis  colli,  and  suprascapular.  This 
arrangement  existed  in  34  of  52  cases,  the  variations  from  this  order 
being  about  equal  upon  the  two  sides.  In  2  of  52  examinations 
the  axis  was  wanting  (both  on  the  right  side),  the  branches  being 
derived  from  different  points. 

The  inferior  thyroid  artery,  the  largest  branch  of  the  axis,  passes 
upward  (inclining  at  first  a  little  inward),  until  it  arrives  at  a  point 
between  the  third  and  seventh  (incomplete)  rings  of  the  trachea, 
where  it  turns  abruptly  inward,  going  behind  the  comrtion  carotid 
and  jugular,  in  front  of  the  vertebral,  and  is  distributed  chiefiy  to  the 
lower  portion  of  the  thyroid  body. 

In  45  of  52  cases  it  came  directly  from  the  axis.  Of  the  7  ano- 
malies of  origin  6  were  on  the  right  side.  It  was  a  branch  of  the 
innominate,  as  shown  in  Fig.  3,  in  3  instances,  two  from  its  posterior, 
and  one  from  its  anterior  aspect.  In  4  other  cases  it  came  directly 
from  the  subclavian.  In  Fig.  4  is  given  the  range  of  origin  of  the 
inferior  thyroid.  Upon  the  right  side  it  is  within  J  inch  of  the 
scalenus  in  89  per  cent.,  and  from  the  upper  portion  of  the  innomi- 
riate  in  11  per  cent,  of  cases.  (In  ligature  of  the  first  portion  of  the 
subclavian  on  the  right  side,  this  vessel  should  be  tied,  and  also  on 
the  left  side  when  the  ligature  is  near  the  scalenus.^)  On  the  left 
side  the  lines  radiating  from  T,  Fig.  4,  show  the  marked  regularity 
of  origin  of  this  branch. 

The  cervicalis  ascendens,  a  small  branch  of  little  surgical  import- 
ance, is  very  irregular  in  its  origin,  as  shown  by  the  following 
synopsis : — 

It  originated  from  the  inferior  thyroid  in 38 

"  "  transversalis  colli  in  .....  8 
"  "  thyroid  axis  (direct)  in  .  ,  .  .  .4 
"  "  superior  intercostal  in  .  .  .  .  .1 
"  "  subclavian  (direct)  in 1 

Cases 52 

The  most  usual  origin  is  therefore  from  the  inferior  thyroid,  and 
just  where  this  vessel  turns  abruptly  toward  the  median  line. 

The   transversalis  colli  passes   outward   in   front   of  the   scalenus 

'  It  is  best  to  tie  the  vessel  on  the  left  side,  well  away  from  the  main  trunk,  on  ac- 
count of  the  thoracic  duct. 


INNOMINATE    AND    SUBCLAVIAN    AllTKIURS.  153 

muscle  and  the  phrenic  nerve^^  underneath  the  oino-liyoid,  and  between 
the  cords  of  the  brachial  plexus,  and  is  distributed  to  the  iTapezius 
muscle,  sending  a  branch  in  the  direction  of  the  posterior  border  of 
the  scapula,  which  anastomoses  with  the  posterior  scapular  artery; 
and  when  tliis  last  vessel  is  not  present,  this  descending  branch  is 
continued  along  the  border  of  the  scapula  to  anastomose  with  the  sub- 
scapular branch  of  the  axillary.  The  iransversalis  colli  was  missing 
in  3  of  26  cases  on  the  rirjJU  side^  being  derived  from  the  axis  in  22 
of  26,  and  from  the  subclavian  in  common  with  the  suprascapular  in 
1  of  26  instances.  On  the  left  side  it  was  from  the  a.xis  in  24  of  26,  by 
a  common  trunk  with  the  suprascapular  alone  in  1,  and  was  absent 
in  1  of  26  cases.  This  branch  will  be  found  wanting  in  the  pro- 
portion of  4  out  of  52  cases,  or  1  in  13.  The  cervicalis  ascendens 
was  a  branch  of  this  artery  in  8  of  52  cases.  In  every  one  of  the 
48  instances  in  which  it  was  present,  it  was  within  a  radius  of  J  inch 
extending  inward  from  the  inner  border  of  the  scalenus  anticus 
muscle. 

The  suprascapular  artery,  intimately  associated  with  the  preceding, 
travels  suddenly  downward  and  outward  from  its  origin  near  the 
inner  edge  of  the  scalenus  a7ilicus,  passes  between  the  subclavian 
artery  and  vein,  in  front  of  the  phrenic  nerve,  crosses  in  front  of  the 
third  division  of  the  main  trunk,  and  goes  to  the  suprascapular 
fossa  under  the  protection  of  the  clavicle,  anastomosing  with  the 
dorsalis  scapulse  of  the  sub  scapular  is.  It  gives  off  a  branch  (fre- 
quently wounded  in  operations  in  this  vicinity)  which  passes  be- 
hind the  sterno-mastoideus  and  along  the  upper  border  of  the  manu- 
brium.    (It  is  not  usually  mentioned.) 

The  suprascapular  was  from  the  axis  in       .         .         .         .         .  46  cases. 
From  the  subclavian  in  common  with  the  transversalis  colli  in     .  2      " 

From  the  internal  mammary  in     .,,...         .  1      " 

And  was  absent  in 3      " 

of  52.     (Twice  absent  on  the  right  side.)^ 

The  superior  intercostal  artery  on  the  right  side  was  present  invari- 
ably. It  was  derived  from  the  1st  division  in  only  6  instances;  in 
20  of  26  from  the  2d  division. 

On  the  left  side  it  was  from  the  1st  division  in  19  of  26  (as  against 
6  of  26  on  the  right  side)  cases,  and  from  the  second  division  in  7 
of  26  cases.     Its  usual  origin  on  both  sides  is  from  ih.Q  posterior  in- 

'  I  have  seen  the  nerve  in  front  of  the  artery  but  once. 

2  Anomalies  occur  much  more  frequently  in  the  right  subclavian. 


154  PRIZE    ESSAY. 

ferior  aspect  of  the  suhclav{a7i,  and  close  to  the  inner  edge  of  the 
scalenus  anticus.     (The  range  of  origin  is  shown  in  Fig.  4.) 

The  profunda  cervicis  was  a  branch  of  the  superior  intercostal  in  35 
of  52  cases;  i.n  15  it  came  direct  from  the  subclavian,  and  in  2  of  52 
it  was  a  branch  of  the  thyroid  axis.  This  vessel  is  usually  yqyj 
small.  I  am  led  to  believe  that  its  importance  as  a  collateral  chan- 
nel after  ligature  of  the  common  carotid  or  first  portion  of  the  sub- 
clavian has  been  overrated.  On  the  right  side,  when  this  branch  was 
not  common  with  the  superior  intercostal^  its  origin  from  the  main 
trunk  was  to  the  outer  side  of  the  intercostal  branch.     (See  Fig.  3.) 

On  the  left  side,  under  above  circumstances,  this  branch  was 
nearer  the  inner  edge  of  the  scalenus  anticus. 

l^he  posterior  scajjular^  one  of  the  most  important  branches  of  the 
subclavian  in  a  surgical  view,  since  it  must  be  in  dangerous  prox- 
imity to  a  ligature  applied  (as  is  most  often  done)  in  the  8d  surgi- 
cal division  (not  given  in  many  standard  text-books,  except  as  an 
occasional  branch  of  this  artery'),  was  present  in  36  of  52  dissections, 
or  69  per  cent.  It  was  present  in  19  of  26  on  the  right  side ;  and  in 
17  of  26  on  the  left.  In  23  of  the  36  cases  in  which  it  was  present, 
it  was  derived  from  the  3d  division;  in  the  remaining  13,  from  the 
2d  division  close  to  its  outer  limit.  In  Fig.  4  the  range  of  varia- 
tion is  shown  in  the  lines  radiating  from  P  S.  On  the  right  side 
74  per  cent,  came  from  the  subclavian  within  ^  of  an  inch  to  the 
outer  and  inner  side  of  the  external  border  of  the  scalenus  muscle; 
26  per  cent,  external  to  this. 

On  the  left  side  82  per  cent,  were  within  |  of  an  inch  to  the  outer 
and  inner  side  of  the  line  dividing  the  middle  and  external  thirds 
of  the  main  trunk  ;  18  per  cent,  were  to  the  outer  side  of  this.  The 
tendency  of  this  important  branch  is  to  originate  near  the  scalenus, 
i.  e.  within  one-fourth  of  an  inch  of  its  outer  edge.  When  tiiis  ves- 
sel is  present  the  transversalis  colli  is  small,  and  when  absent  the  de- 
scending branch  of  the  transversalis  takes  its  distribution.  Passing 
outward  behind  the  most  superficial  cords  of  the  brachial  plexus,  it 
turns  sharply  downward,  along  the  posterior  border  of  the  scapula, 
to  anastomose  with  the  subscapular  branch  of  the  axillary. 

Small  anomalous  branches  were  observed  in  only  9  instances — 

1  from  the  2d  division  of  the  left  side,  4  from  the  3d  portion,  and 

2  from  the  1st  portion. 

On  the  right  side  only  2  small  branches  were  observed,  both  from 

1  Wilson,  Gray,  Morton,  Monro,  Winslow,  Cloquet,  Paxtou,  Richardson,  Leidy. 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES.  155 

tbe  neighborhood  of  the  internal  mammary.  (One  of  tliese  was  the 
comes  nervi  phrenici,  the  other  n  j)ericardiac  branch.)  None  of  these 
had  any  surgical  significance,  being  so  small  that  they  would  not, 
if  present,  contraindicate  the  application  of  the  ligature. 


OPERATIVE  SURGERY. 

From  the  foregoing  dissections  I  would  advise  the  following 
methods  of  procedure  in  ligature  of  the  great  vessels  at  the  base  of 
the  neck. 

Ligation  of  the  Innominate. 

From  the  centre  of  the  interclavicular  notch,  make  an  incision 
about  three  inches  long  along  the  clavicle.  A  second  incision, 
commencing  at  the  inner  border  of  the  sterno-mastoideus  about  two 
inches  above  the  clavicle,  is  made  to  unite  with  the  first  incision  at 
the  middle  of  the  interclavicular  notch.  Dissect  the  flap  upwards, 
until  the  sterno-mastoid  muscle  is  exposed,  which  should  be  divided 
over  the  sternum  and  clavicle  upon  a  grooved  director  carefully  in-- 
troduced.  Superficial  to  the  muscle  some  small  veins  will  be  found, 
and  underneath  its  clavicular  portion  is  the  junction  of  the  subcla- 
vian and  jugular,  in  dangerous  proximity.  (It  is  best  to  leave  some 
of  the  outer  fibres  of  this  muscle  attached  to  prevent  its  retraction 
after  the  operation.)  The  anterior  jugular  veins  will  be  seen  imme- 
diately beneath  this  muscle,  and  should  be  tied  and  divided.  Dis- 
secting carefully,  with  the  handle  of  the  scalpel,  the  connective  and 
areolar  tissue  in  which  these  veins  are  imbedded,  the  origins  of  the 
sterno-hyoid  and  sterno-thyroid  muscles  will  be  reached,  and,  when 
these  are  divided  carefully  upon  the  director,  the  arteria  innominata 
will  be  seen  pulsating  just  behind  the  sterno- clavicular  articulation. 
Being  exposed  with  the  scalpel  handle,  or  any  dissector  not  likely 
to  wound  the  vessel,  the  aneurism  needle  should  be  passed  from 
right  to  left  behind  the  artery,  care  being  taken  to  avoid  wounding 
the  right  vena  innominata  and  the  pneumogastric  nerve,  or  punctur- 
ing the  pleura,  which  the  artery  rests  upan  and  is  partly  imbedded 
in,  and  (if  the  ligature  is  applied  low  down  upon  the  vessel)  the 
left  innominate  vein  which  crosses  in  front.  When  the  aorta  is  situ- 
ated low  in  the  thorax,  it  may  be  necessary  to  remove  the  sternal 
end  of  the  clavicle  and  a  segment  of  the  sternum,  as  was  done  by 
Cooper,  of  San  Francisco,  in  two  instances.     (See  History.) 

From  the  remarkable  results  after  torsion  of  large  vessels  (Bryant's 


156  PRIZE    ESSAY. 

Surgery),  and  in  consideration  of  the  frightful  mortality  which  has 
heretofore  accompanied  this  operation,  I  would  advise  that  the  in- 
norninate,  carotid,  and  subclavian  be  sionultaneously  ligatured  near  the 
junction  of  these  three  trunks,  divided  between  the  ligatures,  and 
each  well  hoisted.  Torsion  of  the  innominate  would  increase  the 
area  of  resistance  to  the  heart's  action,  would  cause  apposition  and 
adhesion  of  the  walls  of  the  artery  close  to  the  aorta,  and  avoid  the 
great  risk  of  the  ligature  cutting  through,  as  a  result  of  the  constant 
pulsation  and  pressure  brought  against  it.  Torsion  of  the  subclavian 
would  occlude  the  vertebral,  internal  mammary,  and  the  thyroid  axis, 
■which  would  obviate  the  necessity  of  their  being  tied  (which  should 
always  be  done  when  torsion  is  not  practised),  since  a  study  of  the 
causes  of  death  in  the  ligature  of  these  large  vessels  has  shown  that 
these  branches  are  among  the  most  important  factors  of  death  when 
left  open.^  Torsion  of  the  carotid  is  not  so  essential,  but  should  be 
performed. 

Ligature  of  the  Right  Subclavian  in  its  1st  Surgical  Division,  or  of  the 
Right  Common  Carotid  at  the  Root  of  the  Neck.  Operation  the  same 
as  for  the  Innom^inate. 

The  subclavian  vein  will  be  found  from  J  to  f  of  an  inch  below 
and  in  front  of  the  artery.  The  internal  jugular  vein  crosses  the 
artery  in  front  of  the  thyroid  axis  at  the  inner  border  of  the  scalenus. 
Between  this  and  the  common  carotid  is  the  vertebral  vein,  and  the 
pneitmo gastric  nerve  in  front,  while  its  recurrent  branch  is  looped 
underneath  and  passes  up  behind  the  vessel.  The  internal  jugular 
vein  should  be  drawn  to  the  side  most  convenient,  the  outer  side 
being  safest  on  account  of  the  right  lymphatic  duct  being  at  its 
junction  with  the  subclavian  vein.  The  phrenic  nerve  should  not 
be  forgotten,  as  it  crosses  the  subclavian  in  front  of  the  last  portion 
of  the  1st  division,  being  in  front  of  the  scalenus  anticus  muscle 
and  behind  the  iransversalis  colli  and  suprascapular  arteries.  (In 
one  instance  I  noticed  a  communicating  filament  from  the  brachial 
plexus  join  the  phrenic  in  front  of  the  artery.) 

The  vertebral,  internal  mammary,  and  thyroid  axis  or  its  branches, 
may  be  secured  by  the  same  operation  as  for  the  ligature  of  the  1st 
surgical  division  on  the  right  side. 

The  vertebral  will  be  found  J  of  an  inch  to  the  inner  side  of  the 
inner  border  of  the  scalenus  anticus  muscle  in  the  vast  majority  of 

'  See  Resume  of  Surgical  History, 


INNOMINATE    AND    SUBCLAVIAN    AkTKIilKS.  157 

cases.  It  is  the  only  vessel  coming  fronn  t})e  posterior  inferior 
aspect  of  the  main  trunk  in  its  1st  surgical  division  (excepting  the 
superior  intercostal  occasionally  seen  on  the  right  side,  oftener  on 
the  left,  but  in  all  cases  much  smaller  than  tlio  vertebrals). 

The  thyroid  axis  and  its  branches  are  in  contact  with  the  inner 
border  of  the  salenus  anticus. 

The  internal  mammary  will  be  found  just  beneath  and  opposite  to 
the  axis.  It  can  be  secured  in  either  of  tlie  5  upper  intercostal 
spaces  by  making  an  oblique  incision,  the  centre  of  which  will  be 
between  ^  and  f  of  an  inch  distant  from  the  margin  of  the  sternum. 
Care  should  be  taken  not  to  wound  the  pleura  in  passing  the  aneu- 
rism needle  around  the  vessel. 

Ligature  of  the  Suhclavian  Arteries  in  their  2d  and  3d  Surgical 

Divisions. 

The  scalenus  a7iticus  muscle  on  both  sides  of  the  neck  is  the  guide 
in  these  operations,  and  it  can  be  found  as  follows:  From  the  mid- 
dle of  the  interclavicular  notch,  measure  alorig  the  clavicle  to  the 
acromion  process.  One-fourth  of  this  distance  from  the  median  line 
will  be  opposite  the  centre  of  the  scalenus  anticus.  Drawing  the 
skin  well  down  upon  the  clavicle,  make  an  incision  through  it  upon 
this  bone,  the  incision  extending  one  inch  toward  the  median  line, 
and  two  inches  toward  the  acromion  process,  from  the  middle  of  the 
scalenus.  Make  a  second  incision  at  right  angles  to  this,  about  IJ 
inch  in  length  in  the  axis  of  the  scalenus,  terminating  in  the  first 
incision  at  the  point  indicated  above  as  the  centre  of  this  muscle. 
The  outer  fibres  of  the  clavicular  origin  of  the  mastoid  muscle  are 
then  divided  upon  a  carefully  inserted  director  (the  large  suhclavian 
vein  is  almost  in  contact  with  this  muscle  here).  The  internal 
jugular  vein  seen  in  the  anterior  portion  of  the  wound  will  be  care- 
fully drawn  to  the  inner  side,  the  operator  keeping  well  above  the 
junction  of  this  with  the  subclavian  and  thus  avoiding  the  lymphatic 
duct. 

A  prominent  plexus  or  group  of  veins,  viz.,  the  external  jugular, 
transversalis  colli,  and  suprascapidar,  will  be  seen  traversing  the 
wound  coming  from  their  respective  origins,  toward  the  subclavian 
near  the  jugidar.  These  should  be  secured  and  divided.  Dissecting 
carefully,  the  su^orascapidar  and  transversalis  colli  arteries  will  be 
observed  running  in  general  in  the  direction  of  the  first  incision. 
The  posterior  belly  of  the  omo-hyoid  may  be  found  in  the  upper 
margin  of  the  wound,  crossing  the  scalenus  at  about  a  right  angle. 


158  PRIZE    ESSAY. 

The  transversaJis  colli  and  the  suprascajndar  may  be  secured  or  held 
to  one  side,  the  finger  passed  along  the  scalenus  until  the  rib  is  felt, 
when  the  artery  will  be  found  just  behind  the  muscle.  If  it  shall 
have  been  determined  to  tie  the  artery  in  its  second  portion,  the 
scalenus  anticus  muscle  will  be  cut  upon  a  director,  the  operator 
being  careful  to  avoid  the  phrenic  nerve  which  crosses  the  muscle  in 
front,  coming  from  above  downwards  and  inwards.  (It  is  between 
the  layers  of  the  sheath  of  this  muscle.)  The  ligature  is  next  passed 
around  the  artery  from  before  backwards,  care  being  taken  not  to 
wound  the  pleura.  In  all  cases  of  ligature  in  this  division,  the 
posterior  scapular  (if  present  and  within  one  inch  of  the  ligature),  the 
branches  of  the  thyroid  axis,  the  vertebral,  and  the  superior  intercostal 
should  be  tied,  in  order  to  remove  the  too  constant  cause  of  secon- 
dary hemorrhage  which  the  resume  of  the  surgical  history  of  this 
operation  will  show  to  be  one  of  the  prime  factors  of  death. 

If  the  third  division  of  the  artery  is  to  be  secured,  the  part  of  the 
above  operation  relating  to  the  division  of  the  scalenus  and  ligature 
of  the  branches  will  be  omitted.  m-\Q  posterior  scajmlar  artery  alone 
will  require  the  ligature,  with  the  common  trunk.  In  this  last 
operation  the  nearest  cord  of  the  brachial  plexus  must  be  carefully 
excluded,  posteriorly  to  the  artery;  the  subclavian  vein  in  front 
and  below.  Depression  of  the  shoulder  and  clavicle  and  extension 
of  the  head  backward  and  slightly  to  the  opposite  side  will  facilitate 
ligature  in  the  first  and  third  divisions  and  in  ligature  of  the 
iniiominctta. 

Ligature  of  the  2d  and  '6d  divisions  of  the  left  suhclavian  is  accom- 
plished by  the  same  procedure  as  for  the  opposite  side. 

The  operation  for  ligature  of  the  1st  portion  of  the  left  subclavian 
is  more  difficult  and  dangerous,  since  the  vessel  is  more  deeply 
situated  and  has  the  thoracic  duct  in  dangerous  proximity. 

Find  the  anterior  scalenus  muscle  by  the  rule  heretofore  given. 
One  inch  external  to  this  point,  commence  an  incision  (the  integu- 
ment having  been  pulled  down  as  before)  which  is  carried  along 
the  clavicle  to  the  sterno-clavicular  articulation.  Divide  the  sterno- 
mastoid,  and  after  this  the  sterno-hyoid  and  ster  no -thyroid  muscles. 
The  subclavian  artery  will  be  seen  ascending  almost  vertically  just 
behind  the  sterno-clavicular  junction.  The  internal  jugular  vein  will 
be  drawn  outward,  and,  passing  the  finger  along  the  inner  border  of 
the  scalenus  muscle,  the  artery  will  be  felt  to  pulsate.  The  thoracic 
duct  usually  is  to  the  right  of  and  a  little  behind  the  artery  oppo- 
site the  upper  border  of  the  sternum.     On  a  level  with  the  insertion 


TNNOM[NATE    AND    SUBCLAVIAN    AP.TRRTES.  159 

of  tlie  scalenus  it  arches  to  the  left,  crosses  in  front  of  tlie  suhclavian, 
in  front  of  the  scalenus^  behind  the  internal  jugular,  and  curves 
downward  to  empty  into  the  subclavian  at  its  junction  with  the 
jugular  to  form  the  left  innominate  vein.  On  account  of  the  intimate 
relations  of  the  thoracic  diict  to  the  left  subclavian  artery  as  this  ves- 
sel goes  behind  the  scalenus^  the  ligature  should  not  be  attempted 
ch)se  to  this  muscle,  nor  should  the  dissection  be  carried  fully  to 
the  scalenus.  The  artery  should  be  tied  as  low  down  as  possible,  the 
duct  being  less  likely  to  be  injured  here,  since  in  passing  behind 
the  aorta  it  is  deeper  than  the  artery.  It  will  be  found  behind  and 
to  the  right,  the  pneumogastric  in  front  and  to  the  right,  the  left 
vena  innominaia  crossing  in  front,  while  the  pleura  is  directly  be- 
hind. (I  consider  this  operation  the  most  formidable  in  the  domain 
of  operative  surgery.  It  has  been  undertaken  only  once  (by  J.  K. 
Eodgers,  of  New  York^);  the  case  terminated  fatally.) 

Ligature  of  the  thyroid  axis  and  internal  mammxiry  artery  near 
their  points  of  origin  on  the  left  side  is  not  justifiable,  on  account  of 
the  proximity  of  the  thoracic  duct,  which  by  virtue  of  its  difficult 
recognition  renders  operative  procedures  in  this  quarter  exceed- 
ingly dangerous.  In  very  rare  instances  an  anomalous  origin  of 
tbe  right  subclavian  artery,  with  absence  of  the  innominate,  may 
occur.  As  seen  in  Fig.  5,  the  order  of  origin  is :  first,  right  and  left 
carotid  (usually  from  a  common  origin),  then  the  left  subclavian, 
and  lastly,  and  from  the  third  portion  of  the  aorta,  the  right  sub- 
clavian. From  this  origin  the  subclavian  passes  behind  the  oeso- 
phagus and  trachea  to  the  right,  and  assumes  its  normal  position 
behind  the  scalenus  anticus.  In  still  rarer  instances  the  aorta  is 
reversed,  and  with  it  the  order  of  origin  of  its  branches. 

'  See  History  of  Ligature  of  Subclavian  in  1st  Surgical  Division. 


SURGICAL  HISTORY 


INNOMINATE  AND  SUBCLAYIAN  ARTERIES. 


11 


162 


PEIZE    ESSAY. 


Ligature  of  the 


No. 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


S.-I 

o 

<«    El 

**-> 

d  <B 

0.2 

°  >^ 

.2  ^ 

-2  s 

;3 

ft  .a 

O 

Ti 

Mott, Valentine, 

New  York, 

May  11,  1818. 


New  York  Med.  Re- 
pository, vol.  i.  1818  ; 

Norri^  Contributions 

to  Practical  Surgery  ; 

Guy's  Hosp.  Reports, 

vol.  xvii.,  Poland. 


Aneurism  of  sub- 
clavian,from  fall 
on  shoulder. 


79  days. 


i  inch 
below 
bifurca- 
tion. 


Feb.  21. 
1S18.  ■ 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES. 

Arteria  Innominata. 


163 


No. 


Pate  of 
operation. 


o   3 

as-. 


11 

P. 

Fl 

o 

O 

,  , 

k 

a 

bo 

'S-. 

M 

C5 

03 
t3 

Recovery. 


(.'oiidition. 


Cause  of  death, 
(late  after  op. 


May  11, 
1818. 


23,24,2.'-. 
and  2G 
days. 


26tli  day.    Hem. 


REMARKS. 


Feb.  21,  1618,  patient  (a  sailor) 
slipped  and  fell  on  deck,  Htrik- 
ing  on  right  arm,  shoulder,  and 
back  of  head.  Not  Hpecially  in- 
convenienced by  fall.  Two  days 
later  BwoUing  and  intense  pain 
in  shoulder.  Entered  New  York 
Hospital  March  1,  1818.  Turnor 
thought  to  be  indolent,  and 
treated  by  blisters.  May  3,  felt 
something  give  way  in  tumor, 
which  increased  in  sine  and  be- 
gan to  pulsate,  both  above  and 
below  the  clavicle.  Symptoms 
increasing  to  May  11th,  opera- 
tion for  ligature  was  made. 
Tumor  had  an  elevation  of  2 
inches,  and  its  diameter  was 
from  4  to  .0  inches  in  every  di- 
rection- It  was  intended  to  tie 
the  subclavian  in  its  firni  ■por- 
tion, but  being  diseased,  the 
innominate  was  tied  on€-half  an 
iQcii  below  the  bifurcation.  The 
ligature  was  of  silk,  and  the  ve— 
sel  was notcntirely  occluded  by 
tli«  operator  at  first  until  some 
minutes  had  elapsed  in  order  to 
arrest  the  column  of  blood  gra- 
dually. Operation  lasted  one 
hour;  tumor  reduced  one-third 
in  size;  wound ■  closed  by  su- 
tures ;  arm  wrapped  in  cotton  ; 
l«ft  carolid  became  very  much 
dilated  and  patient  was  bled  l^i 
ounces  ;  2d  day  doing  well ;  .Sd, 
ditto;  4th,  suppuration  began 
and  continued  to  separation  of 
ISgature  on  Hth  day;  on  16th 
and  after  2M  day,  patient  was 
so  far  improved  that  he  walked 
alone  about  the  hospital  wards  ; 
28d,  -ciemoiThage  from  wound, 
and  on  24th,  2,5t}i,  and  26th  con- 
tinued, and  he  died  on  26th  day 
after  operation  from  loss  of 
I)lood.  Autopsy;  Innominate 
not  closed  on  central  side  of  lig- 
ature ;  on  distal  side  the  ulcer- 
ative process  had  carried  away 
the  remainder  of  the  vessel  and 
portions  of  the  carotid  and  sub- 
clavian, which  last  two  vessels 
opened  into  wound ;  the  sub- 
clavian was  pervious  through- 
out ;  the  carotid  was  not  quite 
occluded ;  the  clavicle  was 
worn  through  about  its  middle  ; 
there  was  no  inflammation  of 
the  pleura,  nor  of  the  serous 
coat  of  the  aorta.  (In  the  ope- 
ration a  vessel  was  divided 
about  a  half-inch  Irom  the  in- 
nominate on  the  lower  border  of 
the  subclavian.  It  is  probable 
that  this  was  either  the  comes 
ne.rvi  plirenici  (see  anatomical 
notes  accompanying  this  essay) 
or  the  sternal  braiich  from  the 
supra-scapular, which  traverses 
this  region.  .\n  abnormal  branch, 
was  found  to  he  derived  from 
the  arteria  innominata  near 
the  ligature.  I  found  this  anom- 
alous vessel  iu  5  of  .34  consecu- 
tive examinations. — Author.) 


164 


PRIZE    ESSAY. 


Ligature  of  the 


No. 


Name  of 
opei'atoi". 


Source  of 
information. 


Graefe,  Berlin, 
1822. 


Norman,  Batli, 
1824. 


Arendt,  St. 

Petersbui'gh, 

1827. 


Hall, Baltimore, 
1830. 


Graefe  &  Walthers' 

Journal,  Bd.  iv. ; 

Guy's  Hosp.  Reports 

(cit.);  Noi'ris  Contrib. 

(cit.). 


Fergusson's  Surgery, 
p.  429,  Phila.,  184.5; 

Norris  Contrib.; 
Guy's  Hosp.  Reports 
(cit.). 
Chelius,  System  of 
Surgery  ;  Norris  Con- 
trib.; Guy's  Hosp. 
Reports  (cit.). 


Norris  Contrib.; 
Dupuytren,  Lemons 
orales  ;  Guy's  Hosp. 

Reports  (cit.). 
Norris  (cit.);  Balti- 
more Med.  &  Surg. 
Journ.,  vol  i.;  Guy's 
Hosp.  Reports  (cit.). 


Cause  of 
operation. 


«.- 

o 

<«  fl 

(._.    ' 

rt  6 

o  o 

o  !» 

S.  5 

■-C  s 

a  !? 

(xi 

5.3 

fi 

'^ 

Aneurism  of  sub- 
clavian. 


About 
1  year.  ? 


do. 


Aneurism  of  sub- 
clavian,  caused 
by   blow  on 
shoulder. 


Spontaneous  an- 
eurism of  sub- 
clavian. 


About 
1  year. 


About 
9  mos. 


1  inch 
from 
aorta. 


^  inch 
below 
bifurca- 
tion. 


INNOMI?fATE    ANT)    SUBCLAVIAN    ARTERIES, 


165 


Arteria  Innominata — continued. 


No. 


Date  of 

operation. 


March  15, 
1822. 


Dec.  24, 

1827. 


Sept.  7, 
1830. 


O    ^    'U 


After 

few 

weeks, 

and  on 

6G  and 
67  days. 


60  t'rs. 


Oc- 
curred, 


During 
opera- 
tion, 
and  im- 
medi- 
ately 
after. 


Uocovory. 


CauHO  of  death, 
dnto  after  op. 


67th  day.    Hem. 


hours.    Hem. 


Sth    day.     Exhaus- 
tion.    (Pyaemia?) 


Hemorrhage. 


REMARKS. 


On  March  l.'i,  1822,  the  oporati-n 
was  made,  intending  to  tie  ilio 
subclavian  in  linjirxt  ptirliuii, 
hut  as  in  the  caee  of  Mott,  this 
vessi^l  was  so  involved  in  the 
disease  that  the  innominate  was 
tied  one  inch  from  the  aortic 
arch.  '1  he  ant-urism  had  exist'  d 
about  one  yi^ar.  Imuiediately 
after  operation,  tumor  diniii- 
ished  in  size,  and  patient  did 
well  for  first  few  weeks.  Hem- 
orrhage occurred  later  and  was 
repeated  until  death  ensued  on 
the  67th  dny.  Autopsy  showed 
that  the  centrril,  ea<X  of  the  liga- 
tured ves'-el  was  clfised  per- 
fectly. The  hemorrhage  was 
from  dist'il  side. 

(Am  unable  to  obtain  details  of 
this  case. — Author.) 


One  year  before  operation  patient 
had  been  struck  on  shoulder, 
which  swelled  immediately,  but 
subsided  on  application  of  cold. 
6  weeks  before  operation  tumor 
had  reappeq.red  and  increased 
rapidly  in  size.  Dec.  24th,  1^27, 
innominate  tied.  lnafewbour.< 
difficult  breathing,  pain,  right 
arm  blue;  bled  patient  2>  oz. 
He  continued  to  grow. weaker 
on  25th,  26th,  27th,  and  2sth  of 
Dec.  0  days  afteroperatiou,  pus 
in  wound,  which  increased  in 
quantity.  Patient  died  8  days 
after  operation,  from  exhaus- 
tion. Autopsy:  Cellular  tissue 
in  region  of  wound  infiltrated 
with  pus.  Innominate  closed, 
ligature  not  being  separated. 
Circumscribed  pneumonia  of 
right  long.     (Pysemia.  ?) 

No  details  of  tnis  case. 


.oth  day.  Exhaus-  Operation  Sept.  7,  18^0  ;  innomi- 
tion  from  hemor-!  nate  diseased  and  dilated  ;  after 
rhage,  venesection  ligature  hem.  from  wound  con- 
(possibly pyajmia),  trolled  by  compression  with 
and  pericarditis.  sponges  ;  1st  and  2d  day  doing 
well ;  was  bled  l.i  ounces  ;  3d 
day,  patient  walked  a  good  deal, 
and  went  intotheyard  ;  1th  diiy, 
sudden  change  for  worse,  and 
died  oth  day  after  the  operation. 
Autopsy:  Pericarditis:  aorta 
enlarged  ;  innominate,  carotid, 
subclavian,  and  aorta  athero- 
matous ;  large  clot  in  sac  ;  an- 
eurism needle  had  partially- 
transfixed  artery,  accounting 
for  hemorrhage. 


166 


PRIZE    ESSAY. 


Ligature  of  the 


No. 


Name  of 
operator. 


Source  of 
information. 


Bland,  1832. 


Lancet,  vol.  i.  p.  97, 

et  seq.;  Guy's  Hosp. 

Keports  (cit.). 


Norris  Contrib.; 

Lancet,  vol.  ii.  p.  44.'5 ; 

Guy's  Hosp.  ileports 

(cit.). 


Cause  of 
operation. 


O    tfl 

u  u 

D 


Spontaneous   an-  2  years 
eurism  of  sub- 
clavian, of  about 
2  years'  dura- 
tion. 


Subclavian  aneu- 
rism,  fall  on 
right  arm  ;   frac- 
ture of  left  clav- 
icle. 


Some 
months. 


INNOMINATE    AND    SUBCLAVIAN    AKTEKIES. 
Arteria  Innominala — continued. 


107 


Date  of 
operatiou. 


9  oC 
a  o  a 
W 


?    O    o 


March  26, 
1832. 


Oc- 
curred. 


May,  SI, 
1837. 


20  and 
22  days. 


Recovery. 


Condition. 


Cause  of  death, 
date  after  op. 


18th  day.  Hern.;  ex- 
hauation. 


22d    day.      Hemor 
phage ;  exhaustion. 


REMARKS. 


AnouriHm  had  cxiRtcd  for  abont 
2  yearn.  Openttion,  Marcli  26, 
18:i2.  Soon  after  operation,  ve- 
nesection 18  ounceM  ;  2d  day, 
venoHection  10  ounces  ;  Hd  day, 
patioiit  easy,  vencKOctlon  \H 
ounccK,  and  purgatives,  and  on 
same  day,  venesection  again  11 
ouuces  ;  4th  day,  venesection  .3 
ounces  ;  .0th  day,  doing  well, 
venesection  2^  ounces,  and 
agaiu  2  ounces  ;  Hth  cay,  vene- 
section 8  ounces  ;  7th,  9  ounces  ; 
8th,  12  ounces;  9th  and  10th, 
doinf,'  well,  and  bled  .')  ounces  ; 
1.1th,  12th,  and  1.3th,  doing  well  ; 
14th,  bled  3  ounces  ;  l.Oth,  some 
fever,  and  bled  14  ounces,  re- 
lieved; 16th,  not  so  well  ;  17th 
day,  hemorrhage  from  wound 
about  .5  ounces,  and  in  evening 
of  the  same  day,  venesection  6 
ounces,  and  again  of  14ounce»<  ; 
18th  day,hem  jrrhage  repeated- 
ly, and  death.  Autopsy :  No 
injury  to  neighboring  parts  by 
operation ;  central  eud  of  in- 
nominate closed  ;  carotid  closed 
completely;  snhclnviaTt  open. 
(The  patient  was  bled  a  total  of 
about  83^  lbs.  and  lost  about  1 
lb.  by  accidental  hemorrhage.) 


4  months  before  operation,  pa- 
tient fell  on  left  shoulder, 
breaking  clavicle.  15  months 
before  operatiou  he  had  fallen 
heavily  upon  right  arm  and  el- 
bow. Tumor  not  observed  until 
a  few  weeks  before  op.,  which 
occurred  May  31,  1S37.  While 
clearing  the  innominate,  the 
thyroidea  ima,  or  some  anom- 
alous branch  was  found,  as  in 
the  case  of  Mott.  In  Lizar's 
operation  it  was  divided.  Few 
hours  after  operation  sense  of 
suffocation  and  piiin  in  chest ; 
2d  day,  better  and  easy  ;  3d,  in- 
ability to  pass  water,  catheter  ; 
4th  day,  pulsation  returned  in 
tumor;  5th,  6th,  7th,  and  8th, 
progressed  favorablv;  9th,  10th, 
11th,  doing  well:  12th,  13th, 
14th,  not  so  well,  vomited  ''Si'J- 
ioMs  -  looking  "  fluid;  16th, 
wound  discharging  pus  ;  17th, 
ligature  loose;  did  well  until 
20th  day,  when  there  was  slight 
hemorrhage  from  wound  ;  vene- 
section -0  ounces,  digitalis,  hy- 
oscyamus  ;  22d  day,  death  from 
hemorrhage.  Autopsy  :  hemor- 
rhage into  pleura  ;  lung  soften- 
ed :  central  end  of  innominate 
not  entirely  closed ;  the  sub- 
clavian was  pervious,  and  the 
hemorrhage  was  supposed  to 
be  from  this  and  the  vertebral. 


168 


PEIZE    ESSAY. 


Ligature  of  the 


No. 


Name  of 
operator. 


Source  of 
information. 


PATIENT. 


Cause  of 
operation. 


.:=:  to 
PL, -3 


pE 


Gore,  Bath. 


Erichsen ;  Guy's  Hosp. 
Reports  (cit.). 


12 


Cooper,  E.  S  , 
1869,  San  Fran- 
cisco. 


do.  1860. 


Pirogoff. 


Hutin  (Oran). 


Smyth,  A.  W., 

New  Orleans, 

1864. 


Mott,  A.  B., 
New  YorIs;,1868. 


Guy's  Hosp.  Reports 

(cit.). 


Allgemein  ;  Krieg's 

Chir.,  1864,  p.  4.'59  ; 

Guy's  Hosp.  Reports 

(cit.). 


Guy's  Hosp.  Reports 

(cit.). 


New  Orleans  Med. 

Press,  May,  1866  ; 

Guy's  Hosp.  Reports. 


Note  to  author. 


Spontaneous  suh- 
clavian   aneu- 
rism. 


Aneurism  of  ca- 
rotid, subclavi- 
an, and  innomi- 
nate. 


Aneurism  of  ca- 
rotid or  subcla- 
vian, or  both. 


Aneurism  of  sub- 
clavian   (trau- 
matic). 


Punctured  wound 
of  branch  of  ax- 
illary, and  after 
ligature  of  sub. 
clavian. 


Subclavian  aneu- 
rism ;    violent 
stretching   of 
arm. 


Subclavian  aneu- 
rism. 


About 
2  years. 


Several 
years. 


About 
3  mos. 


INNOMINATE    AND    SUBCLAVIAN     A  ii'J' K  li  1  E  S. 


109 


Arteria  Innominata — continued. 


No. 


Date  of 
oporatioM. 


0  i> 


Condition. 


Kecovory. 


Cause  of  death, 
days  after  op. 


Sept.  24, 
1850. 


17  th 
day. 


1859. 


None. 


Oc- 
curred. 


Not 
clearly 
stated. 


14th 
day,  15, 
le,  51. 


Recovered. 


Aug.  13, 
1868. 


Oc- 
curred. 


17th    day.      Iletnor- 
rhago. 


91h  day.  Exhau-s- 
tion  (ijrohahly  from 
uvajmia  and  pya:- 
mla). 


.34th    day?    Hemor- 
rhage. 


48  hours.     Pyaemia. 


11  hours.  Exhaus- 
tion from  hemor- 
rhage before  ope- 
ration. 


Cured.  ? 


23d     day.      Hemor- 
rhage iu  thorax. 


Operation,  Sept.  24th,  18.00.  Did 
well  until  5tli  day,  wlicn  o-y- 
KipelaM  ensued  ;  lltli  day,  phle- 
bitlH  ;  17th  day,  r-lot  ol  blood 
eKcaped  from  wound  ilniin(<  a 
fit  of  coughing,  aud  wan  follow- 
ed by  terrible  hemorrhage  and 
deatli  in  a  few  minute«.  Autop- 
sy:  Cardiac  end  of  artery  only 
partially  closed  ;  both  Kubcla- 
vians  closed  ;  carotid  of  riprht 
side  open  ;  purulent  iiiflltratiou 
of  tissue.-i  in  neighborhood  of 
wound. 

Sternal  end  of  clavicle  and  up- 
per portion  of  sternum  removed 
to  facilitate  operation  ;  liitatnie 
close  to  aorta  ;  did  well  for  5 
days,  then  difflculty  of  breath- 
ing, retention  of  urine  ;  flth  day. 
death.  Autopsy:  TuberculoMs 
of  right  lung  ;  pus  in  right  kid- 
ney. 

Operation  same  as  above  ;  pa- 
tient did  well  for  several  weeks, 
when  hemori  hage  occurred  re- 
peatedly ;  patient  becomingdis- 
couraged  Iroui  his  hopeless  con- 
dition, removed  the  compress, 
and  died  on  34th  (?)  day  from 
hemorrhage.     No  autopsy. 

After  operation,  pain  in  right 
side,  difficulty  of  breathing  :  :id 
day,  paralysis  of  left  side  of 
face;  death  in  48  hours.  Au- 
topsy: Purulent  infiltration  of 
pleura  and  mediastinum,  oede- 
ma of  lungs,  and  lobular  pneu- 
monia. 

Patient  received  a  punctured 
wound  in  a  duel  (thoracic 
branch  of  axillary  was  divid- 
ed) ;  subclavian  was  tied  ;  9 
days  later,  to  arrest  hemor- 
rhage, the  innominate  was  tied; 
died  in  11  hours.  Autopsy: 
Hera,  from  thoracic  branch  of 
axillary. 

Aneurism  resulted  from  violent 
stretchiug  of  the  arm  ;  A  months 
later,  innominate  and  carotid 
were  tied  simultaneously;  did 
well  until  14th  day,  when  hem- 
orrhage (16  ounces)  occurred, 
which  was  controlled  by  com- 
press ;  loth  and  16th  days,  con- 
tinued slight  hemorrhage  ;  17th 
day,  wound  was  filled  witk 
S7nnll  shot;  51st  day,  terrible 
hemorrhage  ;  .'J4th  day,  verte 
bral  tied :  .^oth  day,  shot  re- 
moved from  wound  ;  patient 
continued  to  do  well,  and  re- 
covered. (Note. — After  finish- 
ing this  essay,  I  learn  from 
the  New  Orleans  Med.  and 
Surg.  Journal  for  Ju'y,  1S7-5, 
p.  27,  that  this  patient  died  ten 
years  later  from  hemorrhnge 
from  the  original  sac.  Dr. 
Stone  reports  case.) 

The  carotid  was  tied  same  time  : 
sac  was  found  to  have  burst 
into  pleural  cavity. 


170 


PKIZE    ESSAY. 


Ligature  of  the 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

O   Jj 
"S   CI 

ft 

o  .2 

'SI 
■S3 

0  !>. 

1:1 

6 
^  bo 

CO 

bo 

<1 

te  0 

16 

Bickersteth, 
E.  B.,  1SG8. 

Lancet,  Dec.  1872. 

M. 

40 

....  Subclavian  aneu- 

6  w'ks. 

rism(traumatic); 
(strain). 

Ligature  of  the  Subclavian  Artery 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

0 

0 

l| 

Ph  "3 
13 

-•1 
IS 

•«  bo 

01 

bo 

6 

CO 

ft  " 

1 

CoUes. 

Arendt,  1826. 

Mott,  v.,  1831. 

Bayer,  1829. 

Hayden,  G.  T., 

1835. 
O'Reilly,  1836. 

Partridge,  1841. 

Listen,  1830. 

Rodgera,  1845. 

Edinburgh  Med.  & 

Surg.  Journ.,  vol.  xi.; 

Norris  Contrib., 

Phila.,  1873;  Arch. 

Kliu.  Chir.,  Bd.  x. 

Arch.  Klin.  Chir., 

Bd.  X. 

Am.  Jr.  Med.  Sci., 

vol.  xii.;  Norris  (cit.). 

Guy's  Hosp.  Reports, 

vol.  XV. 

Arch.  Klin.  Chir., 
Bd.  X. 

Norris  Coutrib.; 

Am.  Jr.  Med.  Sci., 

1838. 

Norris  ;  Guy's  Hosp. 

Reports,  vol  xv. 

Arch.  Klin.  Chir., 
Bd.  X. 

New  York  Med.  Jr., 
March,  1846;  Guy's 
Hosp.  Reports  (cit.). 

M. 

33 

R. 

Traumatic  aneur- 
ism of  subclavi- 
an. 

2  mos. 

1st  divi- 
sion. 

do. 
do. 
do. 

do. 
do. 

do. 

do. 

do. 

9. 

S 

F. 
M. 

P. 

M. 

M. 
M. 
M. 

21 

21 

57 
39 

38 

32 

42 

E. 
R. 

E. 

R. 
R. 
L. 

Subclavian  aneu- 
rism. 

Subclav.  axillary 
aneurism. 

Subclavian  aneu- 
rism. 

do. 

do. 

do. 

do. 

1  or  2 

years. 
About 

10  w'ks. 

11  mos. 

5  mos. 

7  w'ks. 
4  w'ks. 

4 

6 

6 

7 

8 

9 

INNOMINATE     AND    SUBCLAVIAN    ARTERIES. 


17] 


Arteria  Innominata — continued. 


No. 

Date  of 
oporatiou. 

Hemorrli'ge 
occurred 
after  op. 

<U      ■    Pi 

bo"  « 

RESULT. 

TtEMAKKH. 

Kecovery. 

Condition. 

Cause  of  death, 
date  after  op. 

Mays,  1SG8. 

mh,  0th 
days. 

6th  day.     Hem. 

A   load  wire  was  flrgt   applied, 
but   this  was    removed    on    2d 
day,  and  two  «ill<  ligatures  ap- 
plied    al)OV(!     and     below    thn 
abrasion    caused    by    the    lead 
wire;    a   days   after    this    last 
operation,  hemorrhage,  and  on 
6th   day,  3   more   hemorrhages 
occurred  ;  shot  were  poured  into 
wound;  death.     Autopsy:  Clot 
firm  in   itmoiiitnato  on  cardiac 
side  ;  subclavian  occluded  ;  ca- 
rotid open,  whence  hemorrhage. 

(Bujalski  told  Velpeau  that  he 
had  twice  tied  the  innominate 
with  fatal  results.    The  injiom- 
inate  has  been  exposed  and  not 
tied  on  account  of  diseased  con- 
dition, by  A.  C.  Post,  Mr.  Key, 
Porter  of  Dublin,  and  Doughty 
of  New   York.     This  last  case 
recovered  after  ligature  of  the 
subclavian,  by  A.  B.  Jlott,  the 
carotid  having  been  previously 
tied  by  Doughty.     Peixoto  ex- 
posed   and    passed    a   ligature 
around  this  vessel,  but  did  not 
tie  it,  and  patient  recovered.) 

in  its  First  Surgical  Division. 


Date  of 
operation. 

S  ?,  <u 

a  S-" 

(P   O   t« 

RESITLT. 

REMARKS. 

No. 

Recovery. 

Condition. 

Cause  of  death, 
date  after  op. 

1 

Oct.  10, 

isn. 

Oc- 
curred. 

4th  day.    Hem. 

4th  day. 

18th  day.     Hem. 

24  hours.     Hem. 

12th    day.     Hemor- 
rhage ;'bronchitis. 
13th  day.     Hem. 

4th  day.    Pericardi- 
tis; pleuritis;  pyje- 
mia. 

36th  day.     Hem. 

loth  day.     Hem. 

On  account  of  subclavian  being 

2 

diseased,  the  ligature  was 
placed  in  i  inch  of  innominate; 
pleura  was  wounded  ;  ligature 
not  tightened  immediately. 
Autopsy :  Ulceration  of  sub- 
clavian near  ligature. 

3 

Sept.  22, 

1831. 
Sept.  1829. 

Sept.  15, 

18.3.'). 
April  16, 

1836. 

1841. 

Sept.  20, 
1830. 

1845. 

do. 
do. 

do. 
do. 

None. 

Oc- 
curred. 

13,  15 

days. 

4 

Sac  burst  in  attempt  of  patient  to 

raise  himself  up  in  bed.     Au- 
topsy:    Sac    full    of    stinking 
fluid  ;  2d  and   3d  ribs  carious  ; 
pleuritic  adhesions . 
Autopsy :    At  point  of  ligature 

6 

artery  had  ruptured. 

7 

Autopsy:    No   clot  in   distal  or 

8 

prosinial  side  of  artery. 
Autopsy:    Central   end  of   sub- 

9 

clavian  closed  by  clot  ;  periph- 
eral end  not  closed. 
Erysipelas  on  3d  dav.   Autopsy: 

Proximal  end  of  artery  closed 
by  clot ;  distal  end  where  ver- 
tebral was  given  off.  open;  hem- 
orrhage from  this  point. 

172 


PRIZE    ESSAY. 

Ligature  of  the  Subclavian  Artery 


Name  of 
operator. 

Source  of 
iuformation. 

PATIENT. 

Cause  of 
operation. 

a  6 

O  n 

•J3  =1 

s 
O 

13 

-2  S 

6 

k' 
» 
M 

6 
bo 

■a 

'^  a 

10 

Auvert. 

do. 

Ayres,  S.  C, 
1S61. 

Bullen,  C.  H., 

1864. 

Guy's  Hosp.  Reports, 
vol.  XV. 

do. 

Med.  Surg.  Hist.  Eeb.; 
Dr.  Otis. 

Med.  Surg.  Hist.  Eeb.; 
Dr.  A.  E.  Becker. 

M. 
M. 
M. 
M. 

.50 
36 

2] 

E. 
E. 
E. 
E. 

Subclavian  aneu- 
rism   (reduction 
of  shoulder). 

Subclav.   axilla- 
ry aneurism. 

Shot  wound  frac- 
ture of  clavicle, 
external  3d. 

Shot  wound  near 
acromion. 

9  mos. 


1st  divi- 
sion. 

do. 
do. 
do. 

11 

12 
13 

Nov.  15. 
June  9. 

'Dec.  14. 

June 
28-29. 

Ligature  of  the  Subclavian  Artery  in  its  First  Dimsion, 


Listen,  1838. 


Eossi,  1844. 


Parker,  Wil- 

lard,New  York. 

1S63. 


Hobart,  1839. 


Guy's  Hosp.  Eeports, 
vol.  xvii. 


Gaz.  Med.,  1844,  p.  .'58; 

Arch.  Klin.  Chir., 

Bd.  X. 


Note  to  author. 


Guy's  Hosp.  Eeports, 
vol.  xvii. 


F. 


25 


Subclavian  aneu- 
rism traumatic. 


Innominate  aneu- 
rism. 


Subclavian  aneu- 
rism. 


Aortic  aneurism 
(mistaken  for  in- 
nominate). 


1st  divi- 
sion, 


do. 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES, 


171 


in  its  First  Surgical  Division — continued. 


No. 

Date  of 
operation. 

zl    ^    O 

odd) 

Oj    O    ^ 

w 

(1)       .    P4 

a  o  o 
13 

BBSiriiT. 

RKMARKH. 

Kooovcry. 

Condition. 

Caii«e  of  death, 
date  after  op. 

10 

9,  11. 

13  and 
after. 

None. 

Occur'd 
repeat- 
edly. 

mil  day.     Hem. 

22d     day.      Hemor- 
rhage; pneumonia. 

Half  hour.  Exhaus- 
tion. 

8th  day.     Hem. 

Autopsy;  Proximal  end  cloned 
by  clot;  distal  end  open,  whence 
hemorrhage;  jilciira  and  liiri(f 
involved  in  inflammation  near 
•wound  ;  puH. 

Doing  well  until  Sth  day;  pneu- 
monia; 13th  day,  hernorrliatse, 
and  after  do.  AutopHy:  Proxi- 
mal end  of  artery  closed,  distal 
ojien. 

Hall  emerged  at  back  of  neck, 
near  3d  cervical  vertebra;  had 
fractured  clavicle,  first  rib,  and 
entered  thorax:lnng  hepatized; 
bloody  serum  in  pleura. 

Ball    fractured     acromion,    and 

11 

1^ 

Dec.  14, 
1864. 

June  .SO, 
1864. 

13 

passed  beneath  scapula.  Au- 
topsy :  Subclavian  tied  ^  from 
innominate,  ligature  had  cut 
through  ;  clot  on  cardiac,  none 
on  distal  side. 

and  the  Common  Carotid  {operations  simultaneously). 


July  IS, 
1838. 


1S44. 


Sept.  2,1863 


10,  21, 
35,  42. 


13th  day.     Hem. 


6th    day.     Cerebral 
ansemia. 


42d  day.     Hem. 


16th  day.     Hem. 


Carotid  tied  simultaneously ; 
evening  of  operation,  fainting 
and  collapse  ;  2d,  vomiting:  3d 
day,  pain  in  chest,  venesection 
12  ounces  ;  4th  day,  difficulty  of 
breathing,  venesection  S  oz.  ; 
.oth  day,  cerebral  symptoms  : 
12th  day,  hemoi-rhage  from 
wound  ;  13th  day,  hemorrhage 
and  death.  Autopsy:  Pus  in 
mediastinum;  pericarditis;  in- 
nominate  closed  firmly  ;  carotid 
closed  ;  subclavian  open,  ns 
also  vertebral  and  other  imme- 
diate bran  fhes  :  from  distal  end 
of  subclavian  hem.  had  come. 

At  autopsy,  the  left  carotid  and 
right  vertebral  were  obliter- 
ated. The  only  vessel  going  di- 
rect to  brain  was  left  verte- 
bral. This  case  is  analogous  to 
one  by  Dr.  Hutchison  of  Brook- 
lyn, in  which,  after  ligature  of 
right  carotid,  the  right  verte- 
bral and  left  carotid  were  found 
obliterated  (right  carot'd  tiedk 

The  couiuion  carotid  and  verte- 
bral tied  same  time.  Autopsy 
showed  that  the  fatal  hemor- 
rhage was  from  the  distal  end 
of  subclavian. 

This  patient  had  progressed 
without  an  unfavorable  symp- 
tom until  16th  day.  when  in  a 
fit  of  temper  she  jumped  from 
her  bed.  and  threw  a  pi  How  and 
some  books  at  the  nurse  ;  hem- 
orrhage from  the  carotid  en- 
sued and  death.  Autopsy  show- 
ed the  subclavian  closed  :  the 
carotid  patulotis.  -\lthough 
the  aorta  teas  the  seat  of  the 
disease  and  not  the  innomi- 
nate, the  prilsation  of  tumor 
had  disappeared  before  death, 
and  the  process  of  cure  had 
commenced. 


174 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  First  Division, 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

U    V 

Q 

6 
■or. 
< 

6 

1^  c 

18 

Cuveimer,1859. 
Kuhl,  1836. 

Arch.  Klin.  Chir., 

Bd.  X.;  Gny's  Hosp, 

Reports  (cit.). 

Dr.  C.  Pilz  ;  Arch. 

Klin.  Chir.,  1868; 

Surg.  Anat.  &  Hist. 

Carotid  Arteries. 

M. 
F. 

20 
43 

R. 
R. 

Bayonet  wound 
1st  intercostal 
space. 

Vascular  tumor  of 
frontal  region. 

2i  mos. 

1st  divi- 
sion. 

do. 

19 

Ligature  of  the  Subclavian  Artery  in  its  Second 


Dupuytren, 
1819. 


Liston,  1826. 


Breed,  B.  B., 

1S65. 


Da  Luz,  Lisbon, 
1834. 


Grove,  J.  H. 
1864. 


Nichols,  W.  P., 
Norwich,  1S32. 


Anchincloss, 
Glasgow,  1833. 


Norris  Contrib.  (cit.); 

Arch.  Klin.  Chir., 

Bd.  X.;  Lemons  orales, 

18.34,  vol.  iv.  p.  525. 


Guy's  Hosp.  Reports, 
vol.  XV. 


Med.  Surg.  Hist.  Reb. 


Arch.  Klin.  Chir., 
Bd.  X.  p.  211,  212. 


Med.  Surg.  Hist.  Reb, 


Lancet,  1832-3,  p.  238. 


Edinburgh  Med.  & 

Surg.  Jr.,  vol.  slv., 

1836,  p.  325. 


Mid 
aae. 


Axillary  aneu- 
rism (traumatic) . 


Subclav.  axillary 
aneurism  (trau- 
matic). 


Shot  wound  below 
clavicle. 


Medullary  fungus 
axilla  (thought 
to  be  aneurism). 


Shot  wound  sub- 
clav. axillary. 


Subclav.  axillary 
aneurism  (strain 
in  falling) . 


Subclav.  axillary 
aneurism. 


7  years. 


8  days. 


2d  divi- 
sion. 


Nov.  30, 
1864. 


Oct.  5, 
1864. 


Feb.  27. 


INNOMINATE    AND    SUBCLAVIAN    AIITEUIES. 


17^ 


and  the  Common  Carotid  (operations  simultaneously) — continued. 


No. 

Diito  of 
oporatiou. 

o 

o  g  5 

C   O   cd 

H 

'lO. 
None. 

(D      •   Pi 

RESULT. 

KEMAKKS. 

Recovery. 

Condition. 

Cause  of  death, 
date  after  op. 

18 

Aug.  25, 
1859. 

1836. 

loth  day.     lloiu. 
2d  day.     (?) 

iq 

proximal  end  of  Hiiljclavian ; 
dJHtal  ond  of  Hiiticlaviaii  o))Cii, 
wlionco  hftin'irrliiiL'o. 

to  tio  the  carotid,  and  tliat  t)io 
subclavian  was  included  by 
miHtakc.  Autoptiy;  Pulmonary 
tuborculoHis  ;  cause  of  deatlj 
not  known  ;  carotid  tied  same 
time. 

Surgical  Division  (behind  the  Scalenus  Anticus). 


25 


March  7, 
1819. 


Sept.  14, 
1826. 


None. 


Feb.  27, 
1865. 


Oct.  13, 
1864. 


April  30, 
1832. 


July  23, 
1833. 


13,  14. 


Be- 
fore 

the 
15th. 


Recovered. 


Recovered 


Cured. 


Cured. 


14th  day.     Hem. 


12th  day.  Exhaus- 
tion; pysemia;  gan- 
grene. 


loth  day.     Exhaus 
tion. 


6  hours.    Hem. 


68^  hours.    Cerebral 
symptoms. 


7 years  previous  patient  recoived 
punctured  wound  in  left  .shoul- 
der (from  behind) ;  hemorrhage; 
2month.s  later  aneurism  appear- 
ed, which  seven  years  later  had 
reached  the  size  of  a  child's 
head  ;  3  years  after  ligature  the 
aneurismal  tumor  was  seat  of 
abscess,  which  was  opened,  and 
recovery  took  place. 

Artery  was  first  tied  in  3d  divi- 
sion, but  it  being  involved  in 
disease,  a  ligatnre  was  placed 
behind  scalenus  ;  did  well  until 
hemorrhage  from  wound  on  13th 
day,  which  occurred  again  fa- 
tally on  the  14th.  The  vessel 
had  given  way  near  the  exter- 
nal of  the  two  ligatures,  the  in- 
nermost one  having  become 
loosened.  Both  proximal  and 
distal  ends  of  siibelavian  were 
ox>en. 

Ball  entered  thorax  and  wound- 
ed lung  ;  gangrene  had  resulted 
before  the  ligature  was  applied. 
Autopsy:  Jlultiple  abscesses  in 
both  lungs  ;  clot  in  subclavian. 

Patient  had  a  fungous  growth  in 
left  axilla  ;  attempt  to  remove 
it  ;  hemorrhage  so  profuse,  it 
was  thought  to  be  an  aneur- 
ism ;  ligature  behind  scalenus  ; 
death. 

Ball  entered  at  insertion  of  del- 
toid, and  lodged  between  cla- 
vicle aud  first  rib  ;  patient  did 
not  rally  ;  ball  cut  out  at  ope- 
ration. 

Aneurism  caused  by  strain  of 
arm  in  catching  from  a  fall :  on. 
account  of  nearness  of  tumor, 
the  outer  fibres  of  the  anterior 
scalenus  were  divided,  and  the 
ligature  placed  in  the  2d  divi- 
sion. 

On  the  day  of  operation,  venesec- 
tion 10  oz.  ;  2d  day,  vomited 
greenish  fluid;  ordered  2  grs. 
of  calomel  every  2  hours  ;  died 
comatose.  Autopsy:  Serous  ef- 
fusion beneath  arachnoid:  brain 
slightly  softened  :  purulent  in- 
filtration in  region  of  wound. 


176 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Second 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

g  6 
S  § 

ft 

""  9 

c.o 
'a  'Si 

PL. -3 
■a 

o  \^ 

.2S 

P.S 

6 

bo 

<! 

6 

Ii 

27 

Eoux,  Paris. 

Maladies  des  Art6res 
Quarantes  Annees  de 
Prat.,  vol.  ii.  p.  391. 

M. 

Mid 
age 

R. 

Hemorrhage  from 
punctured    w'nd 
of  axilla  and 
shoulder. 

14  days. 

2d  divi- 
sion. 

28 

Warren,  J.  C, 
Boston,  1844. 

Lancet,  1845,  vol.  ii.  p. 
620  et  seq. 

M. 

30 

L. 

Subclav.  axilla- 
ry  aneurism 
(fall,  and  reduc- 
tion of  shoulder) . 

41  days. 

do. 

29 

V.  Pitha,  1856. 

Arch.  Klin.  Chir., 
Bd.  X.  (cit.). 

M. 

64 

R. 

Axillary  aneu- 
rism. 

do. 

an 

V. Langenbeck, 
1862. 

do. 

M. 

34 

R. 

Diffuse   axillary 
aneurism   (stab 

5  mos. 

do. 

wound). 

SI 

Morton,  T.  G., 
Pliila.,  1866. 

Am.  Jr.  Med.  Sci., 

July,  1867,  p.  70,  and 

July,  1876. 

M. 

51 

L. 

Aneurism,  axilla- 
ry. 

do. 

R? 

Gay,  1871 

(Great  Northern 

Hospital). 

Lancet,  1871,  p.  22; 
do.      May,  1871, 
p.  611. 

M. 

Mid 
age. 

R. 

Subclav.  axillary 
aneurism. 

do. 

Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Eamsden,  1809. 


Blizard,  W., 

1811. 

Colles  (1815), 

1813.  ? 


Arch.  Klin.  Chir., 
Bd.  X.  p.  220. 

Norris  Contrib.  Pract. 

Surgery,  p.  222. 

Alfred  Poland  ;  Guy"s 

Hospital  Reports,  vol. 

XV.  p.  68-69. 


Axillary   aneu- 
rism. 

Aneurism. 

Subclav.  axillary 
aneurism  (fall 
from  horse). 


6  mos. 


3d  divi- 
sion. 


do. 
do. 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES. 


177 


Surgical  Division  (behind  the  Scalenus  Anticus) — continued. 


Date  of 
operatiou. 


>-■  t)  t. 

o  :^  « 


Feb.  8 
1841. 


Nov.  5, 
1862. 


Nov.  14, 
1866. 


March  29, 
1871. 


44,  46, 
47,  68 
days. 


Condition, 


Recovery. 


Recovered. 


Cured. 


Recovered. 


Cause  of  death, 
date  after  op. 


4tli  (or  nth?)  day.  A  grocer  in  jmrHvil  of  a  ciiHto- 
llcmorrliage.  riier  wlio  liiu]  pa-Kfid  ii  coutiier- 

feit  note  ir  trade  with  }iim,waK 
Htiililied  from  Miinii  tlirougb 
ri^'lit  scaiuihi;  Iioiiiorrlia«e  iiii- 
iiiodialc  and  frij-'litfiil;  for  next 
few  (lays, do.; on  121  h  diiy,  Hoiix 
tied  the  axillary;  2  days  later. 
heniiirrliHge  not  beinK  control- 
led, he  tied  HUliclavian  behind 
scalenuK;  hernorrhaj/e  agiiiii  on 
4th  diiy;  amputation  at  shoul- 
dir;  death  in  .i'i  lionrH. 
Dill  well  until  2lHt  day.  whfn 
profuse  venouK  hemoiiliage  of- 
curred  to  amount  of  1  pint; 
pressure;  22d  day,  iineuiin  nia 
.supervenfd;  pulse  returned  in 
radial  artery  on  3Hlst  day. 

6th  day.  Pneumo-' Diffuse  aneurism  resultin,' from 
nia.  rupture  of  circumflex  artery  iu 

attempt  at  reduction  of  shoul- 
der; tumor  size  of  man's  head; 
3d  day  after  operation,  partial 
unconsciousness  ;  6th,  pneumo- 
nia and  death. 

9th  day.  Pysemia.  4  days  after  operation,  fever  and 
rigors,  and  on  9th  d:iy,  death  : 
tlirombus  formed  on  either  side 
of  ligature.  Autopsy:  Adhp- 
sions  between  pleura  and  lung 
on  right  side,  bloody  serous  ex- 
udation in  left  pleural  sac. 
43d  day  after  operation,  abundle 
of  nerves  from  brachial  plexus 
sloughed  away;  44th,  frightful 
hemorrhage;  pressure  and  per- 
salt  of  iron;  46th  and  47th.  also 
hemorrhage;  4Sth,  gangrene  of 
arm  evident ;  5-Sd  day,  ligature 
of  subscapularis  ;  6-'th  day, 
amputation  of  arm  at  upper 
third  ;  6Sth  day,  hem.  again  : 
90th  day,  removal  of  humerus 
at  shoulder-joint. 

9th  day.  Bronchitis;  There  was  no  pulsation  in  the 
pulmonary  conges-  subclavian  when  reacheil  in  the 
tion.  operation.     Autopsy:    Clavicle 

partly  absorbed;  2d  and  3d  ribs 
cut  into  by  al)sorpfion  from 
pressure;  thrombi  on  both  sides 
of  ligature;  lung  inflamed. 


the  outer  edge  of  the  Scalenus  Anticus  and  the  loiver  border  of  First  Bib). 


33 

Nov.  9, 
1809. 

1811. 

181-')  or 
1813? 

5th  day.  Exhaust'n. 

4th  day.  Exhaust'n? 
6th  day.  Exhaust'n. 

Autopsy:  Firm  thrombus  on  both 
sifle.s  of  ligature;  2  lbs.  of  clot- 
ted blood  iu  sac. 

34 

3") 

Delirium  and  rapid  ean^rene  of 

limb  followed  operation.  Au- 
topsy: No  clots  had  formed 
whicli  occluded  the  artery  ou 
proximal  or  distal  side  of  liga- 
ture. 

12 


178 


PRIZE    ESSAY. 


Ligature  of  tie  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
operntor. 


Source  of 
information. 


Cause  of 
operatiun. 


o 

ft 

o  .2 
t3 

3d  divi- 

sion. 

1  m'nth. 

do. 

4  moB. 

do. 

do. 

2  mos. 

do. 

do. 

3  mos. 

do. 

do. 

1  m'nth. 

do. 

do. 

do. 

5  days. 

do. 

do. 

3  w'ks. 

do. 

6  w'ks. 

do. 

«a 


36        Galtie,  1S14. 


Blizard,  T., 
ISlo. 


Warren,  J.  M. 

1847. 


Pirrie,  1838. 

Skey,  F.  C, 

184'J. 

Mackenzie, 

134.i. 

Travers,  1823. 


Bullen,  Thos., 
1823. 


Langenbeck, 
C.  J.  M.,  lS2;i 


Sawinkoff,  1823. 


Datmold.  Wm. 
New  York. 


Ch-amberlaine, 
R. 


Post,  1817. 


Wisliart,  1823. 


Norri.t  Contrib.; 

Arch.  Klin.  Chir. 

Bd.  X. 


Am.  Jr.  Med.  Sci., 
January,  1819,  p.  13. 


Am.  Jr.  Med.  Sci., 

July,  1858,  p.  229. 

Lancet,  1840,  p.  376. 

Arch.  Klin.  Chir., 
Bd.  X.  p.  229. 

Guy's  Hosp.  Reports, 
vol.  XV.  p.  69. 


Lond.  Med.  Repos., 
1823,  vol.  XX.  p.  190. 


Norris  Contrib.,  p.  222. 

Arch.  Klin.  Chir., 
Bd.  X.  p.  222. 


Guy's  Hosp.  Reports 

(cit.),  p.  73. 
Verbally  to  author. 


Abevnethy  in  Med. 

Chir.  Trans.,  ISI.% 

p.  128  et  seq. 


Cooper  in  Med.  Chir. 
Trans.,  1818,  p.  18.1. 


Guy's  Hosp.  Reports, 
vol.  XV.  p.  73. 


Mid 

age 


M. 


L. 


Hemorrhage  after 
disarticulation 
of    humerus    for 
shot  fracture. 


Axillary  aneu- 
rism(traumatic). 


Snbclav.  axillary 
aneurism  (strain 
while  drawing  a 
cork). 

Axillary  aneu- 
rism (strain). 

Subclav.  axillary 
aneurism. 

Hem.  (thrust  of 
red-hot  poker  in 
axilla). 

Subclav.  axillary 
aneurism. 


Subclav.  axillary 
aneurism  (tar 
barrel   fell  on 
shoulder). 


Axillary  aneu- 
rism 

Punctured  w'nd 
axillary  artery. 


Subclav.  axillary 

aneurism. 
Shot   wound    of 

axilla. 


Axillary  aneu- 
rism (punctured 
by  a  cutlass). 


Subclav.  axillary 
aneurism. 


do. 


Oct.  5, 

1814. 


Imme- 
diate 
and 
pre  fuse. 


INNOMINATE    AND    SUBCLAVIAN    ARTEUIES. 


179 


outer  edge  of  Scalenus  Anticus  and  lower,  border  of  First  Bib) — continued. 


Date  of 
oporaliou. 


a  O  o 
1-3  cs  ce 


Aug.  1814. 


Jan.  10, 
Ihlu. 


Dec.  24, 

1*47. 


18.58.  ? 

1840. 

Nov.  19, 
lS4y. 


April  2.3, 
1S23. 


Feb.  8, 1822. 
1822. 


Jan.  17, 
1815. 


Sep.  8,  1817, 


Auff.  22, 
1823. 


Oc- 
curred 


Oc- 
curred. 


16,17, 
26.  75. 


2,3. 


None. 


5,6. 


Recovery. 


Recovered 

Recovered, 
Recovered, 
Recovered, 


Recovered. 
Recovered. 


Recovered. 
Recovered 


Recovered, 


Recovered 


Condition.        Cause  of  death, 
date  after  op. 


Relieved. 

(Small  tu- 
mor per- 
sisted.) 

Cured. 

Cured. 

Cured. 


3d  day.     Hem. 


8th  day.  Cerebral 
symptoms  (proba- 
bly pyjBinia). 


4th  day.  Exhausfn. 


Cured. 


Cured. 
Cured. 


Cured. 


Cured. 


Cured. 


Cured. 


After  rcftoction.  iimpiitJition  and 
ligature  of  axillary  ;  hem.  and 
ligature  of  Hiibdavian  ;  death 
3(1  day.  Antopxy  Hljowed  ulcer- 
ated hole  in  axillary  one  inch 
to  central  Hide  '<(  flr«t  ligature, 
accounting  for  hemorrhage. 

2  days  after  ojieration  sujipura- 
tion  of  sac  eiiHued  ;  7tli  day, 
rupture  and  diHcharge  of  con- 
tents of  sac.  Autopsy:  Throtn- 
burt  on  Vjoth  sides  of  ligature. 

Radial  pulse  returned  on  4th 
day  ;  aneurism  very  much  re- 
duced in  size,  but  a  small  tumor 
containing  fluid  persisted  for 
some  time  after  operation. 


Phlebitis   resulted  after   opera- 
tion. 


In  passing  needle  the  sac  was 
penetrated ;  hemorrha^'e,  which 
did  not  cease  with  the  ligature, 
but  was  controlled  by  conipi  ess. 

(No  anaesthetic.)  Radial  pulse, 
which  was  scarcely  perceptible 
before  ligature,  wns  very  dis- 
tinct after  ;  2d  day,  venesec- 
tion 12  oz.;  Ifith,  hem.  from 
wound;  17th,  do.;  18th,  tumor 
began  to  increase  in  size  ;  26th, 
it  was  punctured  ;  day  before 
patienthad  coughed  upcontents 
of  sac  ;  75tli,  hem.  ;  numbness 
of  arm  during  convalescence. 


Severe  hemorrhage  followed 
wound ;  ligature  of  the  axil- 
lary; new  hem.  and  ligature  of 
subclavian ;  right  arm  remained 
weak  after  convalescence. 


Load  of  bird  shot  entered  axilla 
at  close  range  (2  feet);  uth  day 
after  injury,  subclavian  tied  as 
it  crossed  1st  rib  (incision  be- 
low clavicle);  2  days  after  ope- 
ration, arterial  hemorrhatre; 
pressure;3d,  hemorrhage  a.L'ain; 
recovered;  fixation  of  fingers  in 
flexed  position  as  a  result  of  in- 
jury to  nerves  by  shot.  Below 
clavicle,  at  first  rib. 

Artery  tied  behind  clavicle  ;  Ab- 
ernethy  gives  it  as  subclavian, 
as  "shoulder  was  pushed  up." 
No  bad  symptoms.  Below  cla- 
vicle, at  1st  rib. 

otb  day,  hfmorrhage  (slight) 
from  wound  ;  tith,  do.;  9th,  sac 
bursted,  discharging  3  oz.  dark 
coagulated  blood  ;  12th,  do.  4 
oz.;  \M)x,  14th,  loth,  febrile 
paroxysms  ;  slight  numbness  in 
arm  and  hand  during  convales- 
cence. 

Did  well  until  10th  day,  when 
febrile  symptoms  ensued  ;  ab- 
scess in  axilla  after  convales- 
cence. 


180 


PRIZE    ESSAY, 


Ligature  of  the  Subclaman  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

O    X 

•^  a 
o  o 

a  'S 

S  3 

o| 

w 

a 
br. 

3 

^  0 

51 

Mayo,  1821. 

Stanley  in  Med.  Cliir 
Trans.,  vol.  xii.  p.  12. 

M. 

38 

L. 

Axillary  aneu- 
rism  (rheuma- 
tism). 

3d  divi- 
sion. 

R', 

Wells,  W., 

1828 
(Maracaibo) . 

NorrisContrib.,p.222; 

Am.  Jr.  Med.  Sci., 

1828,  p.  28. 

M. 

61 

R. 

Axillary  aneu- 
rism. 

7  mos. 

do. 

SS 

Listen,  Robert, 
1820. 

NorrisGontrib.,p.222; 

Edin.  Med.  &  Surg. 

Jr.,  vol.  xvi. 

M. 

35 

L. 

Subclav.  axillary 
aneurism. 

5  mos. 

2d  or 
3d.? 

M 

Key,  Chas. 
Aston,  1823. 

Med.  Chir.  Trans., 
vol.  xiii.  p.  1  et  seq. 

M. 

36 

R. 

Axillary  aneu- 
rism  (muscular 

3  mos. 

fif) 

do.  1822. 

Gibbs,  H.  L., 
1823. 

NorrisContrib.  p.  222. 

exei'iion). 
Aneurism, 

Subclav.  axillary 
aneurism  (struck 
with  rope). 

fifi 

B.  C.  Brodie  in  Med. 

Chir.  Trans.,  vol.  xii. 

p.  531. 

M. 

35 

L. 

1  m'nth 

3d  divi- 
sion. 

fi? 

Brodie,  1831. 

Guy's  Hosp.  Reports, 
vol.  XV.  p.  69. 

M. 

50 

R.    Snhclav.  a.xillarv 

2mo<. 

do. 

aneurism. 

fiS 

Baroni,  1 823. 

Mem.  Med.  Soc.  de 

Bouloifne  ;  Norris 

Contiib. 

M. 

Wound  of  axilla. 

A  few 
days. 

do. 

fi9 

Arendt,  1826. 

Thorpe,  Robert, 
1827. 

Arch,  fiir  Klin.  Chir., 

Bd.  X.  p.  222. 

Am.  Jr.  Med.  Sci., 

vol.  il.  1828,  p.  136  ; 

MeJ.  Chi'-.  Rev.,  1828; 

Norris  Contrib. 

M. 
M. 

30 
36 

R. 
R. 

Axillary  aneu- 
rism. 

do. 

Im'nth. 
14  mos. 

do. 
do. 

60 

61 

Wardrop,  1826. 

Lancet,  1826,  vol.  xii. 
p.  471  ;  Arch.  Klin. 
Chir.,  Bd.  x.  p.  223. 

F. 

45 

R. 

Innominate  aneu- 
rism. 

11  mos. 

do. 

69, 

Cooper,  B.,  1827. 

Gibson,  W., 

1828. 

Norris  Contrib  ,  p.  224; 
Am.  Jr.  Med.  Sci., 

182S. 
Am.  Jr.  Med.  Sci., 
vol.  ii.,  182S,  p.  136. 

M. 
M. 

38 
35 

R. 
L. 

Axillary  aneu- 
rism. 

Wound  of  axilla- 
ry  (reduction   of 
shoulder-joint). 

3  mos. 
2  days. 

do. 
do. 

63 

INNOMINATE    AND    SUBCLAVIAN    ARTKUIES, 


181 


outer  edge  of  Scalenus  Anticus  and  lower  border  of  First  Rib) — continued. 


No. 


Dato  of 
operation. 


Hemor 
occur 
after 

J    ^   m 

'^ 

Recovery. 


CiiuHo  of  death, 
date  after  op. 


5S 


March  19, 
1S21. 


Alirin2, 

182S. 


April  3, 
1820. 


Sept..  19, 
.      1823. 

1822. 
Jail.  5, 1823, 


1831. 


Jan.  17, 
1S23. 


June  6, 

1826. 
June  21, 

i827. 


July,  1S23 


1,10,11, 
12. 


Dec.  4, 1827 


March  17, 
1S2S. 


Repeat- 
edly. 


Recovered. 


Recovered. 


Recovered. 


12th  day.     Horn. 


Cured. 


Cured. 


Cured. 


Cured. 


Recovered.       Cured, 


Recovered, 


Temporary 
relief. 


th  day.  Inflamma- 
tion of  siic ;  pl«u- 
ritis  ;  pericardits. 


7th   day.      Exhaus- 
tion.   (Pysemia.)? 


60th  day.     Exhau; 
tlou  and  hem.  from 
sloughing  of  sac. 

6th   day.      Exhaus- 
tion ;    gangrene 
(Pysemia?) 


PulKe  returned  In  8ac  2d  day, 
and  vem^Hcction  to  18  oz.;  3d 
day,  vnesction  KJoz.  and  leech- 
es ;  6th,  hern,  from  wound  (over 
a  pint)  ;  loth,  venftsi'ction  16 
07,.,  and  calotriel.  jalap,  and 
salts,  also  liemorrhaL'e  1/;  pint; 
11th  day,  hem.  from  wound; 
12th,  do.  and  death.  Autopsy; 
Artery  divided  hy  lii^atiire; 
central  end  open  ;  distal  clused 
by  clot;  slight  pleuritis  and 
adhesions;  first  three  ribs  partly 
absorbed 

Patient  thought  aneurism  -was 
caused  by  severe  horseback  ex- 
ercise ;  arm  remained  weaker 
than  the  other;  patient  died 
three  year.s  later  of  ulceration 
of  the  bladder. 

(As  the  scalenus  anticus  was 
partially  divided,  this  might  be 
classed  with  the  2d  division 
group  ;  practically  it  is  in  place 
here.)  Violent  hem.  from  the 
external  jugular  occui'red  on 
5th  day:  controlled  by  com- 
press. 

No  unfavorable  symptoms  super- 
vened. 

(Details  not  given  further.) 


Preparatory  treatment  by  vene- 
section and  cathartics  ;  no  bad 
symptoms  noted. 

Suppuration  about  wound  and 
high  febrile  symptoms.  Autop- 
sy: Coagala  on  both  proximal 
and  distal  side  of  ligature:  pur- 
ulent infiltration  near  wound. 

(In  the  Gazette  Medicale,  ]8?5, 
is  a  simple  not'ce  of  this  case  as 
here  given  ;  I  can  find  no  fur- 
ther account.) 


Same  day  of  operation,  venes-^c- 
tion  24  ounces  ;  2d  day.  hemor- 
rhage 30  oz.;  17th  day,  venesec- 
tion 12  oz.;  4  months  after  ope- 
ration, no  pulsation  in  radial. 

Symptoms  of  dyspniBa  which  had 
existed  previous  to  operation  in 
a  severe  form,  disappeared  after 
operation  ;  patient  died  of  the 
aneurism  2  years  later  ;  cause 
of  dea^h,  bronchitis,  anasarca, 
diarrhoea,  and  aueurism.  Au- 
topsy: Subclavian  oeclud^'d  : 
aorta  and  great  vessels  athero- 
matous ;  large  aneurism  of  in- 
nominate extending  into  neck. 

This  operation  is  stated  to  have 
lasted  only  l-i  minutes  :  rei'eat- 
ed  hemorrhage  followed. 

4th  and  -ith  day  arm  mmh  swol- 
len ;  gangrene  ensued  ;  deliri- 
um. Autopsy :  Extensive  in- 
flammation of  axilla  ;  cardiac 
end  of  artery  was  not  filled  with 
clot. 


182 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
operator. 


Source  of 
informatiou. 


PATIENT. 

<S 

61) 

£» 

<i 

m 

Cause  of 
operation. 


o  >> 

5   3 


64       Textor,  1828. 


65  i  De  Haen,  1828. 

66  Baker,  1828. 


67     Balardini,  1828. 


Porter,  1829. 

Crossing,  1830. 

Bland,  1830. 

Delpech,  1830. 

Buclianau,  M., 
1830.  ? 

Mott,  v.,  1830. 


Roux,  Pli.  J., 
1830. 


Mayo,  1831. 

Brodie,  1823. 

Fergusson, 
Wm.,  1831. 


Porter,  1831. 
Blasius. 


Buenger,  1S32. 

Lallemand,  F., 
1833. 


Arch.  Klin.  Chir. 
Bd.  X.  p.  223. 


Dr.  Jones  in  Lancet, 
vol.xvi.,  1S28-9,  p.210, 


Norris  Contrib.; 

ircli.  Klin.  Chir., 

Bd.  X.  p.  224. 


Dublin  Hosp.  Reports, 
vol.  V.  p.  198  ;  Guy's 
Hosp.  Reports,  vol. 

XV.  p.  73. 

Med.  Chir.  Trans., 

vol.  xvi.  p.  344. 

Norris  Contrib.,  p.  224, 

Arch.  Klin.  Chir., 

Bd.  X.  p.  224. 

Lancet,  1830-1,  p.  452. 


Notes  from  Prof.  A.  B 

Mott;  Am.  Jr.  Med. 

Sci.,  1830,  p.  309. 

Arch.  Klin.  Cliir., 

Bd.  X.  p.  224. 


Norris  Contrib.,  p.  224, 

Arch.  Klin.  Chir., 

Bd.  X.  p.  222. 

Ed.  Med.  &  Surg.  Jr., 

vol.  xxxvi.,  1831,  p. 

309. 


Norris  Contrib.,  p.  224 

Arch.  Klin.  Chir., 
Bd.  X.  p.  225. 


Arch.  Gen.,  1835,  t.  7, 
April,  p.  477  et  seq. 


M. 

20? 

R. 

M. 
P. 

18 

R. 

P. 

60 

R. 

M. 

40 

L. 

M. 

46 

R. 

M. 

63 

R. 

M. 

L. 

M. 

55 

M. 

28 

R. 

M. 

22 

L. 

M. 

49 

L. 

M. 

56 

L. 

M. 

60 

R. 

M. 

63 

L. 

P. 

33 

R. 

M. 

Y'g 

M. 

R. 

Aneurism,  axilla- 
ry (traumatic?). 


Aneurism,  axilla- 
ry. 

Fungus  of  axilla 
(supposed  aneu- 
rism) . 

Aneurism,  axilla- 
ry   (result  of 
fracture  of   hu- 
merus). 


Subclav.  axilla- 
ry aneurism  (id- 
iopathic). 

Axillary  aneu- 
rism(idiopathic). 

Aneurism. 

Axillary  aneu- 
rism). 

Hemorr'ge    (after 
amputation). 


Axillary  aneu- 
rism (strain). 


Hemorrhage  after  9  days, 
ligature  of  axil- 
lary. 


3d  divi- 
sion. 


do. 
do. 


Aneui-ism. 

Subclavian  aneu- 
rism. 

Axillary  aneu- 
rism. 


Sarcomatous   tu- 
mor of  mamma. 


Punctured  wound 

of  axilla. 
Sword   thrust   in 

axilla. 


Im'nth, 


2  years. 


5  -w'ks. 
1  year. 


do. 

do. 
do. 

do. 
do. 


do. 
do. 
do. 


do. 
do. 


Feb.  If 
1833. 


INNOMINATE     AND    SUBCLAVIAN    ARTERIES. 


183 


Older  edge  of  Scalenus  Anticus  and  lower  border  of  Firal  Uih) — continuod. 


Datn  of 

oporation. 

QJ    O    03 

Id 

July  28, 
lb28. 


Aug.  1S28. 
182S. 


Nov.  24, 
1S2S. 


1S29. 


June  2.3, 

1S30. 

Dec.  17, 

1S:W. 
1S:50. 

May  ],  1830. 


Aug.  30, 
1830. 

Aug.  2,5, 
1830. 


March  26, 

1831. 
March  7, 

1S23. 
May  12, 

1831. 


Dec.  31, 
1831. 
1831. 


1832. 


Feb.  19, 
1S33. 


Oc- 
curred, 


Oc- 
curred. 


16, 17, 


Recovery. 


Kecovorod. 


Recovered. 

Recovered. 

Recovered. 
Recovered.? 


32 


Recovered. 


Recovered.       Cured 


Condition. 


Cause  of  death, 
dale  after  op. 


REMARKS. 


Cured. 

Cured. 

Cured. 


Cured. 


4th  day.    ? 


Exhaust'n;  disease. 


30th  day.  Suppura- 
tion  of  sac;  exhaus- 
tion. 


Recovered. 


Recovered. 


Recovered. 
Recovered. 


Cured. 


Cured. 
Cured. 


No  Hpecial  caiiBn  of  death  ih 
given.  At  tlio  autoi'ny  a  cord 
of  the  liriichial  plwxiiH  wan 
fouiid  witliin  the  ligature. 


Tumor  dimininhed  in  nize  imme- 
diately after  ripoiation,  but  waH 
not  cured.  Autopsy:  Sulcla- 
vian  ohl  iterated  by  tlie  ligature. 

Aneurism  aftor  fracture  of  the 
huitierns;  venesection  and  ice 
did  not  arrest  its  development. 
Autopsy:  The  central  end  of 
the  subclavian  was  found  oblit- 
erated (condition  of  the  distal 
end  not  given). 

Inflammation  and  suppuration  of 
sac  on  2.5ih  day;  large  abscess 
opened  on  4.ith  day. 

13th  day,  slight  hemorrhage  from 
wound  and  vene-ecticn  Iti  oz. ; 
1-tth  day,  venesection  again  1 6  oz. 


Patient  fell  in  vat  of  lye,  which 
necessitated  amputation  of  arm 
aljove  elbow  :  hemorrhage  en- 
sued ;  ligature  of  subclavian ; 
death  6  days  later. 

Discharged  cured  27  days  after 
operation. 

27  days  before  operation,  disar- 
ticulation of  hnmerub  for  gun- 
shot wound  ;  19ih  and -0th  days 
before  operation,  hemorrhage  ; 
subclavian  tied  bplow  clavicle; 
hemorrhage  again,  and  subcla- 
vian tied  npar  scalenus  ;  on  ac- 
count of  hemorrhage,  patient 
was  transfused,  but  died  in  a 
few  minutes.  Autopsy:  Pleuro- 
pneumonia ;  thrombi  above  and 
below  the  first  ligature. 


oth    day.     EKhaus-  Autopsy:  Thrombi  on  both  sides 
of  ligature. 

6  weeks  before  operation  tnmor 
had  grown  rapidly  ;  a  good 
sized  segment  of  the  artery 
came  away  with  the  ligature; 
33d  day,  sliaht  oozing  hem.  ; 
34th,  do.:  37th,  large  abscess  in 
axilla  punctured. 


6th    day. 
tion. 


Few  minutes.  Ex- 
haustion from  hem. 
before  op.  above 
clavicle. 


tion;  gangrene. 


20th   day.    Septice- 
mia. 


Tumor  result  of  blow  ;  3th  day, 
fever  and  rigors,  and  suppura- 
tion;  difficult  breathing,  es- 
hanstiou.  death.  -Autopsy;  Pus 
infiltration  in  region  of  wound  ; 
artery  still  closed  by  ligature  ; 
no  clot  on  cardiac  side. 


Sth  day,  diarrhoea  ;  12th,  do.,  and 
on  this  day  the  large  abscess  in 
axilla  was  punctured,  giving 
escape  to  an  enoruiou-  quant' ty 
of  bloody  pus  :  radial  pulse  re- 
turned ;iOtli  dny. 


18J: 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  {between 


Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

11 

.-  bo 

13 

a!2 

V,  bo 

CO 

bo 

< 

3 

CO 

.a 

82 

Kuhl,  1834. 

Arch.  Klin.  Chir., 
Bd.  X.  p.  225. 

M. 

22 

R. 

Axillary  aneu- 
rism, punctured 
wound. 

15  days. 

3d  divi- 
sion. 

Feb.  10. 

11-25. 

f^3 

Nicol,  Jno.  I., 
1834. 

Ed.  Med.  &  Surs^.  Jr., 
vol.  xlii.,  1834,  p.  1. 

M. 

68 

L. 

Medullary  sarco- 
ma of   humerus 
(supposed   aneu- 
rism). 

do. 

S4 

Seutin,  1834. 

Guy's  Hosp.  Reports, 
vol.  XV.  p.  72-3. 

M. 

44 

L. 

Subclav.   axilla- 
ry  aneurism 
(syphilis). 

do. 

S.i 

Lizars,  1S34. 

Lancet,  183.3-4,  vol.  ii. 
p.  717. 

F. 

Mid 
age. 

L. 

Axillary  aneu- 
rism. 

10  y'rs. 

do. 

Sfi 

Earle,  183;). 

Hobarr,  1836. 
Montani,  1836. 

Rigaud,  1836. 

Michaelis, 
1836-7. 

Mussey,  1837 
(New  Hamp- 
shire). 

Norris  Contrib.,  p.  224; 

Arch.  Klin.  Chir., 

Bd.  X.  p.  224. 

Guy'.s  Hosp.  Reports, 

vol.  XV.  p.  74-). 

Arch.  Klin.  Chir., 

Bd.  X.  p.  223. 

Archives  Generales, 
t.  xii.  1836. 

Arch.  Klin.  Chir., 
Bd.  X.  p.  226. 

Am.  Jr.  Med.  Sci., 
1837,  p.  390. 

M. 

M. 
M. 

M. 

M. 
M. 

54 

38 
21 

31 

L. 

R. 
R. 

E. 

Subclav.   axilla- 
ry aneurism. 

do. 

Axillary  aneu- 
rism (punctured 
wound). 

Axillary  aneu- 
rism (punctured, 
thought  to  be  ab- 
scess). 

Punctured  wound 
of   axillary  ar- 
tery. 

Removal  clavicle 
and  scapula   for 
osteo-sarcoma. 

10  mos. 
4  mos. 

do. 

do. 
do. 

do. 

do. 
do. 

87 

88 
89 

90 
91 

June  12. 

Imme- 
diate. 

40 

92 

Jobert,  1837. 

Guy's  Hosp.  Reports, 
vol.  XV.  p.  73. 

M. 

61 

R. 

Subclav.   axilla- 
ry aneurism(car- 
rying  weight  on 
shoulder). 

4^  mos. 

do. 

93 

White,  1838. 

Norris  (cit.),  p.  226  ; 

Arch.  Klin.  Chir., 

Bd.  X.  p.  227. 

M. 

Y'g, 

L. 

Aneurism,  axilla- 
ry   (punctured 
wound). 

2  w'ks. 

do. 

INNOMINATE    AND    SUBCLAVIAN    AltTEUIES. 


185 


outer  edge  of  Scalenus  Antiaus  and  lower  border  of  First  Rib) — continnod. 


Bate  of 
operation. 


g  5c 

«  o  te 
W 


Recovery. 


Condition. 


Cause  of  death, 
date  after  op. 


REMARKS. 


Feb.  25, 
183i. 


Jan.  17, 
1S.J4. 


April  27, 
1S34. 


April  1,8, 
1835  ? 


1S36. 
June,  1836. 


1S36. 


Sept.  28, 
1837. 


Sept.  17, 
1S3S. 


Cth. 


26  and 
after, 
and  35. 


None. 


Recovered. 

Recovered 
Recovered. 


Cured. 

Cured. 
Cured. 


Recovered. 


Recovered 


Cured. 


Cured. 


Recovered. 


Cured. 


Otli  day.     Hem. 


2.') til  day.  Diar'hcea; 
liciii.:  exhaustion. 


3Jtli  day.     Hem. 


15  dayH  before  operation,  Hword 
thriiHt  in  duel  ;  hem.  next  day, 
andHwoUlnjf  in  axillary  region; 
2Jth  Feb.,  ligature  :  2d  day,  ab- 
HceHH  opened,  and  4  IhH.  of  blood 
and  pnM  CHcaped  ;  fjth  day.  vio- 
lent hem.  from  wound  of  liga- 
ture, and  patient  died  before  Dr. 
K.  arrived.  Autopsy  :  Nothing 
of  intele^t. 

5th  day,  patient  became  lethar- 
gic ;  Kith  day,  inflammation  of 
wound  and  sup)iuratioJi  ;  vene- 
section 8  oz.;  after  this  did  well 
until  2lKt  day.  when  after  for- 
bidden exertion  he  was  ''  de- 
luged in  blood."  Auti'psy  Car- 
diac end  of  artery  closed  by  clot, 
dintal  mfl  opfu. 

Tumor  full  of  fibrin;  2d  rib 
eroded  ;  purulent  infiltration  of 
parts  above  wound  ;  no  clot  on 
cardiac  or  distal  side  of  ligature. 

Last  six  months  before  operation, 
tumor  had  grown  rapidly;  8 
days  before,  "felt  something 
give  way  in  the  axillary  le- 
gion;" pulse  in  ladial  in  lO 
hours ;  operator  thought  the 
subclavian  was  in  front  of 
scalenus  anticus  ;  was  nut  pos- 
itive ;  tumor  at  last  account 
had  diminished  i  in  size. 


Suppuration  of  sac  after  opera- 
tion. 

46lh  day.  Exhaus-  Venesection  in  course  of  treat- 
ment after  operation  ;  IMh  day, 
large  abscess  formed  in  sac. 


29th    day.      Hemor- 


19  years  previously,  metacarpal 
bone  had  been  removed  for  dis- 
ease ;  11  years  later,  arm  ampu- 
tated at  shoulder  for  same  affec- 
tion ;  6  years  after  last  opera- 
tion, subclavian  tied  in  opera- 
tion for  removal  of  olavicle  and 
scapula;  wound  united  by  1st 
intention;  during  the  operation, 
subclavian  vein  was  wounded 
and  air  entered. 
\5  days  after  operation,  aneurism 
hage,  exhaustion.  ]  developed  on  cardiac  side  of 
ligatui-e ;  abscess  formed  on 
shoulder.  Autopsy:  Purulent 
infiltration  among  tissues:  both 
euds  of  artery  open  and  in  pus  : 
general  atheromatous  condition 
of  vessels. 
Following  the  wound,  severe 
hemorrhage  which  was  arrested 
by  compression  ;  4  days  later, 
aneurism  appeared :  after  the 
ligature,  the  abscess  in  axilla 
was  punctured  with  great  re- 
lief. 


186 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  [between 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


rt" 

o 

iiO 

^ 

o 

t3 

fi.a 


Nott,  Josiah  C. 
(Mobile),  183S. 


Syme,  183 


9°  1  HuUon,  J.  P., 
!  1841. 


Am.  Jr.  Med.  Sci., 
vol.  ii.  n.  s.,  1841. 


Arch.  Klin.  Chir., 
Bd.  X.  p.  227. 


Lancet,  1810-1,  vol.  ii.   M. 
p.  377. 


Pfister,  1840. 


Gross,  Prof. 
S.  D..  1841. 


Hutin,  1S41. 


McDougall, 
18-12. 


Arch.  Klin.  Chir. 
Bd.  X.  p.  227. 


Am.  Jr.  Med.  Sci., 

vol.  X.,  1815,  p.  19; 

Norris,  p.  226. 


Guy's  Hosp.  Reports, 
Bd.  X.  p.  138,  vol.  xvii. 


NorrisContrib.,p.226.!  M. 


22 


Aneurism,   shot 
(.small-sized 
shot)  wound  ax- 
illa. 


Axillary  aneu- 
rism (after  fall). 


Axillary  aneu- 
rism   (fall,   and 
catching  violent- 
ly by  arm). 


2  mos.   3d  divi- 
sion. 


Axillary  aneu 
rism  (punctured 
wound). 


Some 

weeks, 

3? 


Axillary  aneu- 
rism. 


Wound  of  axilla- 
ry, scissors- 


12  days. 


Aneurism  (shot 
wound). 


do. 


Sept.  23. 


12th 
day, 
13-16- 


Extra- 
vasat'n 
immedi- 
ate. 


Dec.  17. 
1840. 


Several 
times. 


Oct.  28, 
1831 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES. 


187 


outer  edge  of  Scalenus  Anticus  and  lower  border  of  First  Bib) — continued. 


No. 


97 


Hato  of 
operation. 


Nov.  27, 
1838. 


Oct.  2S, 
1838. 


Jan.  8, 
1841. 


Jan.  8, 

1841. 


Feb.  18, 
1S41. 


Nov.  9, 
1841. 


101       Dec.  12, 

1S41. 


0    0   0, 

at 


So  often 
that  S. 
had  to 
ampu- 
tate at 
shoul- 
der. 


Oc- 
curred. 


Recovery. 


Kocovered. 


Recovered. 


Recovered. 


Condition. 


Cause  of  death, 
date  after  op. 


Cured  (with 
loss  of  arm). 


Cured. 


lotli  day.     Hem. 


30th  day.  Exhaus 
tion,  rupture  of  sac 
into  pleura. 


10th  dny.     Exhaus- 
tiou,  hem. 


ith  day.     Hem 


REMARKS. 


fiun  dlBcharped  in  axilla  at  rIo«e 
range ;  hemorrhage  on  12th, 
KUh,  and  Ifith  days  ;  com[TO»s  ; 
in  2  nioiitliH  annurintii  aippeared  ; 
operation  miccoHKful  in  all  re- 
Kppcts ;  2  ynarK  after  operation 
patient  wll. 

ThefriKhtful  hernorrhaffe  occur- 
red through  thetinbHcapularis  of 
axillary,  which  was  found  to 
be  torn. 


3  weeks  after  fall  and  strain  of 
arm,  aneurism  appparod  ;  HO 
days  after  ligature  the  sac, 
which  had  diminished  in  size, 
began  to  inciease  rapidly  ; 
punctured  and  discharged  pus. 
(Although  the  incisions  were 
made,  and  the  artery  reached 
ahove  the  clavicle,  the  operator 
says  the  artery  was  tied  2  in- 
ches below  this  bone  !  Such  a 
procedure  is  scaicely  possible. 
— Author.) 

3  weeks  before  oper'n,  wounded 
with  pointed  instrument  in  ax- 
illH  (from  behind)  ;  on  account 
of  hemorrhage  attempt  to  tie  ax- 
illary, whi'hbeing  wounded  by 
the  aneuiism  needle,  the  sub- 
clavian WHS  secured  ;  hemor- 
rhage, rigors,  and  death.  Au- 
topsy showed  hemorrhage  to 
have  come  frum  cardiac  e  d  of 
subclavian  n en r  ligature,  whi  h 
had  partially  cut  through  the 
3  coats  of  the  artery. 

After  ligature  the  tumor  became 
solidified  ;  2")th  day.  fever,  tu- 
mor red  with  inflammation  and 
painful ;  2(ith,  severe  pain  in 
chest ;  2Sth  day,  patient  felt  as 
if  fluid  was  passing  from  pleura 
iuto  aueurismal  sac  ;  died  30th. 
Autopsy:  Between  1st  and  2d 
ribs  sac  communicated  with 
pleura  by  free  opening:  3  qts. 
of  bloody  serum  in  right  pleural 
cavity. 

"  Soldier,  fighting  duel  with  scis- 
sors blade  attached  to  end  of 
stick,"  was  wounded  in  ax'.Ua: 
12  days,  ligature  of  subclavian; 
6  days  after  ligature,  patient 
got  out  of  bed,  contrary  to  or- 
ders, went  to  water  closet,  and 
in  act  of  defecation  hemorrhaLC 
from  axilla;  compress  :  9th  day, 
on  account  of  continued  hemor- 
rhage, H.  tied  the  inni'mh'atn; 
died  next  morning.  Autopsy: 
Tlie  only  source  of  hemoirhage 
w:is  found  to  be  one  of  the  tho- 
racic branches  of  the  narillary  ; 
no  other  points  of  interest. 


188 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  {between 


Name  of 
operator. 

Source  of 
infoimation. 

PATIENT. 

Cause  of 
operation. 

o 

03  cS 

fl.3 

>M  bo 

bo 

6 

CO 

o3  O 

OS 

101 

Post,  A.  C, 
lS4i. 

N.  Y.  .Tr.  Med.,  vol. 
iv.,  March,  J  84.5. 

M. 

37 

R. 

Hem.  (wound  of) 
axilla    (scythe- 
blade). 

21  days. 

3d  divi- 
sion. 

Nov.  15. 

Imme- 
diate. 

^o?. 

Cooper,  B.  B., 
1.S41-9.  ? 

Gny's  Hosp.  Reports, 
vol.  XV.  p.  70-1. 

M. 

50 

L. 

Subclav.  axillary 
aneurism. 

6  w'ks. 

do. 

108 

Wattman,  1843. 

Arch.  Klin.  Chir., 
Bd.  X.  p.  228. 

Subclav.  axillary 
aneurism   (shot 

10+ 

Mott,  v.,  1844. 
Knorre,  1845. 

Dr.  A.  B.  Mott  to 
author  ;  N.  Y.  Jr., 

Jan.  184.5. 

Arch.  Klin.  Chir., 

Bd.  X.  p.  229. 

M. 
M. 

35 

22 

R. 
R. 

wound). 
Axillary  aneu- 
rism (shot  w'd). 

Hem    (abscess  in 
axilla). 

22  days. 

3d  divi- 
sion. 

do. 

10.5 

106 

Green,  1844. 

Guy's  Hosp.  Reports, 
vol.  XV.  p.  70-1. 

M 

.So 

R. 

Subclavian  aneu- 

do. 

rism. 

107 

Vanzetti,  1P46. 
Syme,  1847. 

Arch.  Klin.  Chir., 

Bd.  X.  p.  229. 

Ed.  Monthly  Jr.,  1848, 

p.  217. 

M. 
M. 

40 
34 

L. 
R. 

Axillary  aneu- 
rism. 

Axillary  aneu- 
rism. 

17  mos. 

do. 
do. 

lOS 

109 

Manec,  1848. 

Arch.  Klin.  Chir. 

M. 

18 

L. 

Subclav.  axillary 
aneurism  (shot 
wound). 

7  days. 

do. 

June  24. 

Soon 

after, 

and 

July  2. 

110 

Hancock,  1848 

Lancet,  1849,  p.  126 
et  seq. 

M. 

34 

Axillary   aneu- 
rism (sack   of 
beans   fell  on 
shoulder). 

2  years. 

do. 

111 

Linhart,  1848. 

Arch.  Klin.  Chir., 
Bd.  X.  p.  229. 

M. 

Mid 
age. 

R. 

Shot   wound 
(shoulder-joint). 

A  few 
hours. 

do. 

11'^ 

Ci-ompton,  1849. 
Syme,  1849. 

Unknown, 

Scblesswig- 

HolsteiQ  War, 

1S48-.50. 

do. 

do. 

Parker.  Prof. 

Willard,  18i9. 

do.  p.  230. 

Ed.  Monthly  Jr., 
March,  18-50,  p.  240. 

Arch.  Klin.  Chir., 
Bd.  X.  p.  230. 

do. 

do. 
Notes  of  cases  fur- 
nished to  author  by 
Prof.  ParKer. 

M. 
M 

M. 

M. 
M. 
M. 

49 
50 

Tf 

Axillary  aneu- 
rism. 

Axillary  aneu- 
rism   (thrown 
from  carriage). 

m 

R. 

is  days. 

3d  divi- 
sion. 

do. 

do. 
do. 
do. 

114 

ITi 

neighborhood  of 
axilla. 

do. 
do. 

Traumatic  aneu- 
rism and  hemor- 
rhage of  axilla. 

IIR 

117 

31 

R. 

Feb.  5, 
1849. 

INNOMINATE    AND    SUBCLAVIAN    AUTKRIES. 


189 


outer  edge  of  Soalenua  Anlicus  and  lower  bot-der  of  First  liib) — continued. 


naio  of 
operation. 


u  o 


r;  t.  ^ 

o  S  a> 


to 

■a  i 


Recovery. 


Condition. 


CauHe  of  (loath, 
date  after  op. 


Dec.  (), 
181;3. 


1841  ? 
1843. 


April  11, 
184i. 

April  6, 

184). 


Aug.  17, 
1S46. 

July  ^9, 
1&47. 


July  2, 

1848. 


1848. 


March  23, 

1849. 

Oct.  23, 

1849. 

1S4S-J0. 


do. 

do. 

Feb.  23, 

1S49. 


None. 


Oc- 
curred, 


None. 


26 


Recovered. 


Cured  (Iosh 
of  arm). 


Recovered. 
Recovered. 

Recovered. 


Recovered. 


Recovered. 


Recovered. 
Recovered, 


l.Oth  day.  Pleuritis, 
pneumonia,  empy- 
ema. 

Hemorrhage.     ? 


Cured. 
Cured. 

Cured. 


Cured. 


37th  day.     Hem. 


Next  day.  Exhaus- 
tion, pneumo-tho- 
rax. 


Cured. 
Cured. 


Pysemia. 


do. 
do. 


Cured  (with 
loss  of  use 
hand  from 
ulceration). 


I"im<'iliatf!ly  after  wound,  axil- 
laiy  artrry  lied  by  Dr.  Cox  of 
WilliamnburKli,  N.  Y.  ;  next 
day,  arm  amputated  by  Or. 
PoHf,  2  inohoH  below  head  of 
liumerus  ;  in  tliiK  operation,  ax- 
illary tied  }  inch  above  l)r.  C.'h 
ligature  ;  14  days  alter  amputa- 
tion, arterial  hemorrliage  12  oz.; 
21  days  after  amputation  a  pro- 
fuse arterial  henjorihage  neces- 
sitating ligation  of  subclavian  ; 
external  jugular  vein  divided, 
and  oir  entered  w.in ;  recovered 
with  no  unusual  symptoms. 

No  autopsy. 


11th  day  after  operation,  tumor 
discharging  freely ;  no  bad 
symptoms. 

Absiess  had  been  opened  and 
hemorrhage  resulted  for  seve- 
ral days  ;  recovery  very  slow, 
hut  without  bad  symptoms. 

In  operation,  nerve  of  brachial 
plexus  was  included  in  liga- 
ture ;  ou  account  of  the  intense 
pain,  ligature  was  removed  and 
re-applied  ;  recovered  without 
a  had  symptom. 


16  years  previously,  patient  fell 
down  stairs  and  strained  his 
arm  ;  10  months  before  opeia- 
tion,  tumor  increased  rapidly; 
no  had  symptoms  followed  ope- 
ration. 

During  ofieration,  external  jug- 
ular vein  was  cut  and  air  en- 
tered ;  recovery  slow  ;  bull  en- 
tered just  below  clavicle  and 
was  cut  out  of  the  infra-spinous 
fossa. 

Was  bled  on  admission  :  27th 
day,  sac  opened  and  dischar^'ed 
quite  a  quantity  of  offensive 
blood  and  pus  :  37th  daj-,  hem. 
and  death.  Autopsy  :  Artery 
closed  by  clot  on  both  sides  of 
ligature;  fatal  hemorrhage  from 
branches  between  ligature  and 
sac. 

Resection  of  humerus  immedi- 
ately after  injury.  Autopsy: 
Ball  had  entered  thorax  in  3d 
intercostal  space. 


Erysipelas  supervened  about  23d 
day :  no  other  unfavorable 
(■yojptoms  noted. 


Patient  was  well   and  a  useful 
man  many  years  after  operat'n. 


190 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


o  X 

u 


Parker,  Prof. 
Willard,  1859. 


do.  1S60. 

do.  1S61. 
Goetze,  1850. 


Lohmeyer,  1850. 


Notes  of  cases  fur- 
nished to  author  by 
Prof.  Parker. 


do. 

Arch.  Klin.  Chir., 
Bd.  X.  p.  230. 


Holt,  Barnard,   Lancet,  1852,  vol.  i.  p. 
1851.  120  ;  1853,  vol.i.  p.  13:^ 


Mackenzie, 
E.J. 


Gore,  1851. 

Van  Buren, 
Wm.  H.,  1S52. 


Hamilton,  Prof. 
Frank  H.,  1852, 


Miller,  1853.  ? 


Ed.  Monthly  Jr.,  Jan. 
and  March,1852,  p. 110. 


Guy's  Hosp.  Reports, 

vol.  XV.  p.  72-3. 

Contnb.  Pract.  Surg. 

V.  B.,  1865. 


Notesofcaseto  author 


Arch.  Klin.  Chir., 
Bd.  X.  p.  231. 


Aneurism  axilla. 


do. 


Shot  wound  under 
clavicle. 


15  days 


Axillary  anenr. 


Subclav.  aneur. 

Aneurism,  stab 
wound. 


3d  divi- 
sion. 


do. 

do. 
do. 


23  days. 


do. 


5  w'ks. 


3  w'ks 


Removal  of  large 
sarcoma  from  ax- 
illa. 

Axillary  aneur. 


do. 
do. 


Oct.  4, 
1850. 


INNOMINATE    AND    SUBCLAVIAN    ARTERIP:^, 


191 


Older  edge  of  Scalenus  Anticus  and  lower  border  of  First  Rib) — continued. 


No. 


Date  of 
oiieration. 


120 
121 


122 


125 
126 


127 


Doc.  13, 
1809. 


Nov.  13, 
1860. 

Oct.  2, 

lS(il. 
Nov.  2, 
1S50. 


Nov.  3, 
1850. 


June  19, 
1851. 


Nov.  19, 
1851. 


1S51. 
1852. 


June  23, 

1852. 


18.'i3.     ? 


o  s  0) 

So  .*•' 
OJ  o   « 


Noae. 


None. 


Oc- 
curred. 


Oc- 
curred 


Recovery. 


Coadltion. 


Cause  of  death, 
date  after  op< 


15 
sliglit. 


None. 


Eecoverod, 
Kecoverod, 


Eecovered, 


Recovered. 


4tli  day.     Shock. 


Cured. 
Cured. 


Cured. 


Recovered. 


Cured. 


5th  day.     Hem. 


Hemorrhage. 


27th     day.     Hem. 
pysemia.    ? 


Cured. 


Cured. 


Thi«  m!in  liad  KyphiliH,  and  wa» 
of  l.ail  and  illHKi|.at(;d  hul.itK, 
a  lid  could  not  rccovr  from  the 
Kliock  of  HO  foimidablc  an  ope- 
ration. 

No  bad  HyrnptomM  are  noted  In 
the  course  of  recovery. 

The  aneurism  was  caused. after 
ting  a  bag  of  grain. 

Ball  (iutorod  two  fingers' breadth 
below  nii'ldlo  of  clavicle,  and 
p'riHscd  throngb  axilla  and  out 
through  scapula;  hcinorrliMge 
on  15th  day  after  injury,  which 
recurred  5  times;  4th  day  after 
operation,  2  severe  heni'jrrhaaes 
and  death.  Autopsy  :  Hemor- 
rhage from  distal  end  of  artery, 
which  was  found  open. 

Ball  entfred  below  clavicle, 
passed  through  axilla,  and  out 
through  scapula  near  spina 
scapulaj  ;  wound  healed  nicely 
until  23d  day  ;  hemorrhage  ;  4 
days  later,  hemorrhage  again  ; 
after  ligature,  hem.  ceased  un- 
til 3d  day  ;  on  4th,  recurred, 
and  death.  Autopsy  did  not  re- 
veal the  source  of  the  hr-rn. 

During  the  operation  a  large 
branch  thought  to  be  transver- 
salis  colli  (more  probably  the 
posterior  scapular  —  Author) 
was  mistaken  for  the  subcla- 
vian. After  the  lik'ature  was 
applied  to  subclavian,  pulsa- 
tion in  sac  ceased,  but  the  con- 
tents remained  fluid  for  some 
time. 

6th  day,  rigors,  bronchitis  ;  ISth, 
slight  hemorrh'e  from  wound; 
19th,  do.  slight;  20th  day,  do. 
profuse,  arrested  by  compress  ; 
death,  27th.  Autopsy:  Subcla- 
vian vein  behind  scalenus  anti- 
cus ;  large  abscess  in  pleural 
cavity  extending  fi-om  4th  rib 
upward  ;  cardiac  end  of  artery 
open  ;  distal  end  closed. 

Hem.  profuse  immediately  after 
injury;  arrested  by  pressure; 
2d  day  after  ligature,  symp- 
toms of  gangrene  ;  4th  day,  line 
of  demarcation  ;  7th  day,  one 
pound  of  coagulated  blood  es- 
caped from  sac;  15th,  erysipelas 
and  slight  hemorrhage  ;  within 
next  mouth,  erysipelas  reap- 
peared several  times,  and  pa- 
tient was  at  times  delirious. 

Dr  H.  writes:  ''Whether  the 
tumor  returned  I  do  not  know, 
as  I  lost  sight  of  patient  some 
months  after  the  operation."' 


192 


PRIZE    ESSAY. 


Ligature  of  the  Suhclaman  Artery  in  its  Third  Surgical  Division  {between 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


Caccioppoli, 

Dom.,  Xaples, 

1S53. 


White,  1853. 


Coppin,  1835. 


Blaker,  185") 


Stanley,  1856. 


Gregg,  1837. 


Soule,  M.  E.,         Arch.  Klin.  Cliir., 
1857.  Bd.  X.  p.  232. 

Clarke,  LeGros.  Lancet,  1859,  vol.  i.  p 
159. 


Gaz.  Med.  de  Paris, 
1854,  t.  ix.  p.  62. 


Ed.  Med.  &  Surg.  Jr., 
1834,  vol.lxxxl.  p.417. 


Arch.  Klin.  Chir. 
Bd.  X.  p.  231. 


Guy's  Hosp.  Reports, 
vol.  XV.  p.  70-1. 


Arch.  Klin.  Chir., 
Bd.  X.  p.  232. 


Guy's  Hosp.  Reports, 
vol.  XV.  p.  72-3. 


Drayton,  H.  E., 
1859. 


Torelli,  1859. 


Arch.  Klin.  Chir.,       M 

Bd.  X.  p.  232. 
Am.  Jr.  Med.  Sci.,       M. 
Oct.  1859,  p.  402 


Arch.  Klin.  Chir., 
Bd.  X.  p.  232. 


Axillary  aneur. 
(spontaneous). 


Shot  wound  of  ax- 
illa :  aneurism. 


Aneurism,  axilla-  3  w'ks. 
ry    (punctured 
wound). 


Suhclav.  axillary  2  years, 
aneurism   (rheu- 
matism). 


Subclav.  axillary    6  mos. 
aneurism. 


R. 


Punctui-ed  wound 
of  axillary. 
Axillary  aneur. 


Suhclav.  axillary 

aneurism. 
Suhclav.  axillary 

aneurism  (fall). 


Axillary  aneur. 
(punctured  w'd). 


3d  divi- 
sion. 


2  mos. 

Aneu- 
rism ex- 
isted 15 

days. 


10  days. 


do. 


do. 


do. 
do. 


do. 
do. 


3  weeks 
before 
opera- 
tion. 


Immp- 
diate. 


March 
25,  1859, 


April  24 


INNOMINATE    AND    SUBCLAVIAN    AUTEKIES. 


193 


outer  edge  of  Scalenus  Anlicus  and  lower  border  of  Firal  Rib) — continued. 


No. 


135 
136 


137 
13S 


Date  of 
oijoration. 


Feb.  13, 
1863. 


April  24, 
18j3. 


.*"'^  <: 
f  £& 

O   C!   S 

"fc-^ 

i"s 

.£!'f*|i 

a,  o  « 

J  is  « 

H 

-o 

Eecovery.     Condition 


1855. 


Aus.  4, 

185ti. 


Dec.  1.3, 

1857. 
1858. 


Feb.  1858. 

April  22, 
1869. 


April  24, 
1859. 


None. 


9,12. 


13 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered 


Cured. 


12tli  day.     Hem. 


3d  day.    Pleuritis. 


Cured. 


Cured. 


Cured. 


Cause  of  death, 
date  after  op. 


RiiMARKS. 


Sth.    day.    Pneumo- 
nia; pysemia.     Im- 
mediate  cause 
hemorrhage. 


ISth  day.     Hem. 


Anenriurn  had  been  faithfully 
troati'd  by  f!li^otro-))unotiire,  Ijiit 
of  no  avail  ;  alter  ligature,  pul- 
Hatiou  irj  tumor  disappeared, 
but  ri'turrjed  in  24  bourn  ;  C. 
tlien  introduced  an  ivory  probe 
between  ligature  and  loop  of 
ligature,  and  left  it  there  for 
some  days.  No  bad  symptomo 
noted. 

Ball  entered  left  axilla  in  front, 
lodged,  and  was  cut  out  of  in- 
fia-s])iiious  fossa  ;  hemorrhage 
immediate  and  profuse,  con- 
trolled by  pressure. 

A  hot  iron  was  tlirust  into  ax- 
illa and  wounded  tlift  artery  ; 
hemorrhage  immediate  and  pro- 
fuse ;  3  weeks  later,  aneurism 
was  discovered  ;  no  bad  symp- 
toms noted  during  recovery. 

Patient  did  well  until  fitli,  when 
hemorrhage  occurred,  which 
proved  fatal  on  12th.  Autopsy: 
1st  and  2d  ribs  eroded  ;  large 
clot  in  sac  ;  proximal  side  of 
artery  healthy  to  near  ligature, 
where  it  bad  sloughed  and  was 
open  ;  distal  side  was  full  of 
purulent  matter  and  uuhealtby. 

Autopsy  :  Pint  and  a  half  of  ex- 
udation in  le.ft  pleural  cavity; 
purulent  infiltratiou  of  tissue-s 
around  wound. 

Pneumonia,  abscess,  symptoms 
of  pysemia,  and  delirium  en- 
sued, and  on  Sth  day,  during  fit 
of  violent  and  delirious  exer- 
tion, fatal  hemorrhage.  Autop- 
sy: Cardiac  end  of  vessel  closed; 
distal  end  open  and  a  large 
sized  branch  opened  here  {sd. 
to  he  iniernaL  mammary  /) 
which  was  cause  of  hem. 


Did  well  to  13th  day;  patient 
quarrelled  with  a  fellow  pa- 
tient, and  in  shaking  his  fist 
hemorrhage  ensued  which  was 
controlled  by  pressure  ;  on  loth 
day,  repeated  hemorrhage,  digi- 
tal pressure  ;  1.5th,  coughing 
and  hem.  ;  17th,  delirium  and 
hem.;  ISth  death.  Autopsy: 
Cardin  c  end  of  artery  open ;  dis- 
tal end  only  partially  occluded. 


22d  day.  Phlebitis;  On  ?th  day  after  operation,  fever 
and  delirium  ;  jumped  from 
bed  and  tore  wound  open ;  no 
hemorrhage.  Autopsy:  Artery 
closed  on  both  sides  of  ligatured 
point. 

10  days  after  injury  aneurism 
formed  rapirtly  :  hemorrhage  on 
24th  of  April. 'and  ligature  ;  24 
days  later,  thumb  and  part  of 
index  finger  amputated  on  ac- 
count of  gangrene  ;  recovered 
with  partial  anchylosis  of  elbow 
joint. 


194 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
opei-ation. 


R.S 


Paget,  1860. 


Buscli,"W.,lS61. 


do.  1S62. 


do.  1864. 


Methner,  1862. 


Bennett,  H.  N. 
(Conn.),  1862. 


Turner,  1863. 


Armsbv,  Prof. 

Albany,  N.  Y.. 

1863. 


Knorre,  1864. 
Vanzetti,  1864. 


Venning, 
Edgecomb. 


Eichet,  1864. 


Browne,  R.  K. 


Segond,  1834. 


Unknown, 
C.  S.  A.,  1863. 


Guy's  Hosp.  Reports, 
voi.  XV.  p.  70-71. 


Arch.  Klin.  Cbir. 
Bd.  X.  p.  233. 


do.  p.  234. 


do. 


Am.  Med.  Times,  Dec, 
27,  1862,  p.  348. 


Dr.  Rodgers  in  Loud, 
Med.  Timps  &  Gaz., 
vol.  ii.,  1863,  p.  485. 

Am.  Med.  Times,  1864. 
p.  54. 


Arch.  Klin.  Chir. 

Bd.  X.  p.  234. 

do. 


Lancet,  186.'},  vol.  ii. 
p.  672. 


Arch.  Klin.  Chir. 
Bd.  X.  p.  234. 


Am.  Jr.  Med.  Sci. 


Worris  Contrib.,  p. 

224;  Arch.  Klin.  Chir. 

Bd.  X.  p.  241. 


Dr.  H.  L.  Thomas, 

C.  S.  A.,  in  Med.  & 

Surg.  Hist.  Reb.,  Part 

I.,  p.  538. 


M. 

54 

R. 

F. 

17 

L. 

F. 

43 

L. 

F. 

42 

R. 

M. 

54 

R. 

M. 

20 

L. 

M. 

27 

L. 

M. 

28 

R. 

M. 

25 

L. 

M. 

40 

L. 

M. 

Mid 
age. 

R. 

M. 

39 

L. 

M 

F. 

40 

M. 

25 

L. 

Subclav.  axillary 
aneurism  (rheu- 
matism). 


(Before  removal 
head  of  humerus 
and   scapula  for 
cancer.) 

Hem.  removal  of 
mammary  gland 


Remov.   humerus 
for  carcinoma. 


3d  divi- 
sion. 


Hem.  (after  rem. 
humerus  for  car- 
cinoma). 

Punctured  knife- 
wound  axilla. 


Axillary   aneur., 
lifting  weight. 


Aneur.,   subclav. 
axillary    (after 
amputation  near 
shoulder). 


Hem.    abscess   in 

axilla. 
Axillary  aneur. 

(punctured  w'd). 


Aneurism,  axilla- 
ry (fall). 


Hemorrhage  (re- 

moval  of  head  of 

humerus). 
Aneurism  axilla 

(pistol   shot 

wound). 


Aneurism  axilla 
(fall, dislocation, 
and   wound   of 
shoulder). 


Shot  wound  lung, 
chest,  and  sub- 
clavian artery  at 
lower  border  of 
1st  rib. 


10  w'ks, 


do. 
do. 

do. 


do. 
do. 


do. 
do. 


July  3, 
1863. 


INNOMINATE    AND    (SUBCLAVIAN    ARTEItlES. 


195 


outer  edge  of  Scalenus  Anticus  and  lower  border  of  First  liib) — continued. 


Diitn  of 
operatiou. 


April,  1861. 


Feb.  8,  1S62. 


July  13, 
18(54. 


Oct.  12, 

1S62. 


June  18, 
1863. 


Nov.  19, 
1863. 


May  19, 
186-t. 

July  27, 
1864. 


Sept.  1864. 


April  5, 
1831. 


July  3, 
1863.? 


13-23- 
41-62- 

65. 


None. 

None. 

None. 
None. 


None 
noted. 


Condition. 


20 


Recovered. 


Recovered. 


Recovery. 


6")th  day.     Iloin. 


Cured. 


3d  day.    Pleuritis. 


.Tth   day.     Septicae- 
mia. 


3d  day.  Exhaustion. 


Cured. 


Cured. 


Recovered.       Cured 


Recovered. 
Recovered. 


Recovered. 


Cured. 

Cured.(?) 


Cured 
(Anchylosis 
of  elbow.) 


Cured. 


Paralysis  of 
left  arm 


Cause  of  death, 
days  after  op. 


REMARKS. 


4tli  week, 
tion. 


Died.    ? 


Exhaus- 


Did  well  till  13th,  horn.;  23d, 
hem.  and  pyajinlc  t<yiiiptom(s  ; 
hem.  on  4lKt,  :')2<l,  and  'i-'Hh  day; 
death.  Autop«y:  Sac  had  »rip- 
puratfd ;  p\in  in  tinHucH  of 
shoulder;  dintal  end  of  li^fa- 
tured  vcHKcl  cloHi-d  ;  cardiac 
end  closed  ;  (hcmorrlia>.'e  most 
prol)al)ly  from  branches  comtiiu- 
riicating  witli  sac.) 

4  years  later  patient  wan  per- 
fectly well. 


Breast  was  extirpated  on  2Sth 
January,  for  carcinoma  that 
had  returned  a  thinl  time  ;  Feb. 
3d,  severe  hemorrhage. 


Patient  died,  in  all  probability, 
from  effects  of  disease  with  loss 
of  blood  before  the  ligature. 

Hemorrhage  after  wound  imme- 
diate and  profuse;  2d  hemor- 
rhage in  a  few  days,  necessitat- 
ing ligature. 

A  large  bianch  running  parallel 
with  subclavian  was  also  tied; 
a  small  sized  tumor  per.sisted 
some  time  after  recovery. 

July  7th,  arm  shattered  by  acci- 
dental discharge  of  cannon ; 
amputation  near  shoulder  3 
dnys  later  ;  .5  mouths,  aneurism 
having  ajipeared,  burst  and 
dischurg'd  3  qts.  of  blood. 


Digital  compression  had  been 
tried  but  failed  ;  after  reeoveiy, 
tumor  diminished  iu  size,  but 
was  filled  wiih  liquid. 

Hemorrhage  occurred  after  ope- 
ratiou in  October;  pyaemia  also 
ensued. 


(Author  read  notice  of  this  case 
and  took  notes  at  time  as  given, 
but  failed  to  note  date  of  jour- 
nal. The  case  as  given  is  reli- 
able.)— Aiithnr. 

Patient  slipped  and  fell  upon  an 
earthen  vessel,  dislocated  arm, 
and  wounded  axilla  with  frag- 
ments driven  in  ;  humerus  re- 
duced by  non-professioual ;  4  or 
5  days  later,  profuse  hemor- 
rhage, and  one  month  later, 
aneurism. 

'One  of  the  nerves  of  the  bra- 
chial plexus,  ]irobably.  having 
been  included  in  the  ligature." 
(Although  this  accident  has 
happened  in  several  instances, 
the  paralysis  iu  this  case  could 
equally  have  been  due  to  injury 
from  missile. — Author.) 


196  PRIZE    ESSAY. 

Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  {between 


No. 


Name  of 
operator. 


Source  of 
information. 


PATIENT. 

6 

6 

bn 

CO 

<i 

m 

Cause  of 
operation. 


e.-. 

O 

a  6 

o  .2 

0  t^ 

■^  s 

■5  ^ 

-2  3 

tS  :e 

03 'S* 

^1 "» 

Q 

na 

°-9 


155    Azpell,  Thos.F.,  Med.  Surgf.  Hist.  Eeb., 
U.  S.  A.,  1862.  Part  I.,  p.  538, 


159 

160 


Unknown, 
C.  S.  A.,  1863. 


Pancoast,  G.  L., 
?U.  S.  A.,  1865. 


Gross,  F.  H., 
U.  S.  A.,  1864. 


Fuller,  E.  S.  E. 

1864. 
Slirady,  Geo.F. 

1861. 


Curtis,  Edward, 
1864. 


162 


Dr.  H.  L.  Thomas, 

C.  S.  A.,  in  Med.  & 

Surg.  Hist.  Reb.,  Part 

I.,  p.  53S. 


Med.  Surg.  Hist.  Reb., 
Part  1.,  p.  539. 


Unlcnown, 
Surgeon  C.  S.  A. 


Mosely,  N.  R., 
1864. 


do.  p.  539. 
do. 


Aneurism,   shot 
wound  left  axil- 
la. 


Shot  wound  left 
axilla. 


Shot  wound  i-ight 
axilla. 


R.   Shot  wound  right 
axilla  :  aneur 


Dr.  H.  L.  Thomas  in 

Med.  Surt;.  Hist.  Reb.. 

p.  540. 


Med.  Surg.  Hist.  Eeb., 
p.  340. 


164        Townsend, 
T.  B.,  ?  1864. 


21      R. 


Mid 
age 


7  days 


15  days. 


43  days. 


106 
days. 


Shot  wound  axil- 
lary artery. 

Hem.  shot  wound 
axilla. 


11  days. 

12  days. 


28  days, 


3d  divi- 
sion. 


do. 


Hem.   wound   of 
right  shoulder. 


22  days. 


Hem.  shot  wound  14  days 
right  axilla. 


Shot  wound  left 
shoulder  and  ax- 
illa. 


29  davs. 


do. 
do. 


do. 


do. 


April  7, 
1862. 


July  2, 

18lJ3. 


M'ch2.5, 
1865. 


June  5, 

1864. 


April  8. 


Imme- 
diate. 


Mch29. 


None 
noted. 


Nov.  30,  Oc- 

1864.  curred. 

May  9,  do. 

1864. 


June  27. 


Sept.  19, 
1863 


June  3 
1864. 


May  20, 
1864. 


July  14 
and  24. 


Oc- 
curred. 


INNOMINATE    AND    SUBCLAVIAN    AfiTEIUKS. 


197 


outer  edge  of  Scalenus  Anticua  and  lower  border  of  First  Rib) — continued. 


DatH  of 
operation. 


o  a 
o>  o 


'6| 


Recovery, 


Condition. 


Cause  of  death, 
date  after  op. 


REMAICKS. 


155 


156 


159 
160 


April  14, 
18b2. 


July  17, 
1863. 


May  7,  1865. 


Sept.  19, 
1864. 


Dec.  11, 

1864. 

May  .31, 

1864. 


July  25, 
1864. 


5tli  day. 

Three 

times. 


2  days. 


Oct.  11, 
1863. 


June  17, 
1864. 


June  IS, 

1864. 


Imme- 
diate. 


None. 


None. 


12tli 
day. 


None. 


Recovered, 


Recovered, 


Recovered. 


Partial  diH- 
il)ility  of 
left  arm. 


Total   disa- 
bility of 
aim. 

Not  cured 
of  aneu- 
rism. 


5th  day.     Hem. 

50  hours.     Exhaus- 
tion; hemorrhage. 


'Ball  entered  near  collar  bone, 
cut  out  lower  ed>{e  of  Hcapula, 
atropliy  of  niiiscles  of  arm  and 
shoulder.  JJiKability  one-half 
torniiorary.  Still  a  pensioner  in 
1872." 

Great  tumefaction  in  region  of 
wound  ;  aw  h^morrhaf^e  did  not 
coase  with  ligauire  of  subcla- 
vian, tho  siipra-«cai)ular  was 
also  tied  ;  ligature  from  supra- 
scapular on  Kith  day:  no  bad 
symptoms  followed  ;  ball  enter- 
ed 1)4  inch  below  left  scapula, 
ranj^ed  forward,  and  lodged. 

Musket  ball  through  the  light 
shoulder  and  axilla  ;  disability 
total ;  still  pensioned  in  1872. 


Ball  entered  one  inch  below  cen- 
tre of  right  clavicle,  and  passed 
directly  through.  In  1867  "no 
use  of  right  arm,  total  disability 
from  arienrifim  alone,  liable  to 
death,  by  rupture,  upon  any  ex- 
ertion." In  1872,  still  a  pen- 
sioner. 

Hem.  occurred  from  sloughing  of 
axillary  artery. 

Minnie  ball,  in  through  pecto- 
ralis  major,  and  out  2  inches 
above  posterior  f(  Id  of  axilla; 
2  days  after  ligature  of  subcla- 
vian, a  vein  was  tied  at  .seat  of 
wound.  Autop.sy:  slough  had 
destroyed  portion  of  supra-sca- 
pular artery  and  axillaiy  vein. 

Ball  entered  right  shoulder  pns- 
teriorly  and  lodged  in  axilla, 
passing  through  scapula  just 
below  spine ;  17  diiys  after 
wound,  hemorrhage  3  pints, 
ligature  of  axillary :  10  days 
later,  hemorrhage,  and  on  the 
next  day,  2S  days  after  injury, 
ligature  of  the  subclavian.  Au- 
topsy uot  given  ;  hemorrhage 
reported  as  from  riistal  side  of 
ligature  aud  irova.  distal  end  of 
nxillary. 

Ball  fractured  head  of  humerus, 
near  coracoid  prucess,  and  pass- 
ed out  above  spitia  scnpvlcB. 
Fever  and  suppuration  follow- 
ed; after  ligature  of  subclavian 
(9  days)  gangrene  supervened. 

Patient  was  of  hemorrhagic  dia- 
thesis aud  was  suffering  from  a 
cough  ;  artery  gave  way  12th 
day,  and  death  was  almost  in- 
stantly the  result.  "There  were 
slight  fibrinous  exudations  on 
either  side  of  where  the  liga- 
ture cut  through."'  (I  judge 
from  this  that  the  hemorrhage 
was  at  the  seat  of  ligature,  and 
pi-obably  from  cardiac  side  — 

I   Author') 

6th  day.  Gangrene;  Ball  entered  under  spine  of  left 
exhaus'n;  pyaemia,  scapula  and  rauged  toward 
chest  ;  gangrene  and  hemor 
rhage  followed  ;  after  ligature 
of  subclavian,  no  hemorrhage, 
but  rigors  and  pyaemic  symp- 
toms. 


16lh  day.     Exhaus 
tion;  hemorrhage. 


10th  day.  Gangrene; 
exhaustion. 


I2th  day.     Hem. 


198 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Snrgical  Division  (between 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

O 

0 

S  3 
p. 2 

0) 

6 

"2 

ft  s 

W 

< 

JB 

p 

-d 

,0 

165 

Browa,  F.  H..? 

Med.  Surg.  Hist.  Keb., 

M. 

Mid 

L. 

Shot  wound   arm 

23  days. 

3d  divi- 

May 31, 

June]  9. 

1S62. 

p.  540. 

age 

and  axilla. 

sion. 

1862. 

166 

Hodsren,  J.  T., 
1862. 

do. 

M. 

19 

L. 

Shot  wound  left 
axilla. 

19  days. 

do. 

Oct.  3, 

1862. 

Oc- 
curred. 

167 

Sheldon,  A.  V., 
1S64. 

do. 

M. 

22 

E. 

Shot  wound  righ 
arm   and  shoul- 
der. 

11  days. 

do. 

May  8, 
1864. 

May  29. 

168 

Allen, Harrison, 
lS6i. 

Med.  Surg.  Hist.  Reb., 
Part.  I.,  p.  541. 

M. 

28 

R. 

Shot  wound  right 
axilla  andshoul- 
der. 

9  days. 

do. 

Oct.  27, 
1864. 

Oc- 
curred. 

169 

Gross,  Prof. 

Dr.  Jno.  J.  Eeese  in 

M. 

Mid 

L. 

Shot  wound  left 

8  mos., 

do. 

June  25, 

M'ch  14. 

S.  D.,  1863. 

Med.  Surg.  Hist.  Eeb., 
p.  541. 

age. 

axilla;  hemor'ge 
diffuse  aneurism 

20  days. 

1862. 

170 

McClellan,  E.,  ? 
1863. 

do. 

M. 

39 

L. 

Shot  wound  left 
shoulder ;  aneu- 
rism. 

58  days. 

do. 

April  2, 
18B5. 

Several 
times. 

171 

Baylor,  J.  C, 
1863. 

Dr.  P.  F.  Browne  in 

Med.  Surg.  Hist.  Reb., 

p.  541-2. 

M. 

Mid 
age 

R. 

Shot  wound  right 
axilla. 

38  days. 

do. 

Nov.  8, 
1863. 

172 

Selden,Wm., 
1864. 

Surg.  Hist.  Eeb., 
p.  542. 

M. 

29 

L. 

Shot  wound  left 
axilla. 

39  days. 

do. 

June  14, 
1864. 

Imme- 
diate 
and 
profuse. 

INNOMINATE    AND    SUBCLAVIAN    ARTERIKS. 


199 


outer  edge  of  Scalenus  Antious  and  lower  border  of  First  Bib) — continued. 


No. 


PatGof 
operation. 


n  ° 


1^  ri  « 


Eocovery, 


Condition. 


Cause  of  death, 
date  after  op. 


REMARKS. 


166 

107 


Juno  23, 
18U2. 


Oct.  22. 

May  29, 
18()4. 


Nov.5,  1804. 


March  1.5, 
1S63. 


May  30, 
18S5. 


Dec.  16, 
1863. 


July  23, 
1S64. 


None. 


7-9  ? 
17-21. 


10,  11. 
13days 


None. 


Next 
day. 


None. 


4th  day.  Pya3nila.(?) 


0th   day.     Exhaus- 
tion; hemorrhage. 
21st  day.     Hem. 


13th  day.     Hem. 


2d  day.  Exhaustion 
(shock  ?) 


12th  day.  Exhaus'n 


IS  hours.     Exhaus- 
tion ;  hemorrhage. 


Sth  day.  Hemor- 
rhage ;  erysipelas 
pleuritis. 


Ball  entered  left  arm  at  del- 
toid inKcrtion,  out  at  poHterior 
border  of  axilla;  bone  not  in- 
jured ;  ureat  proHtration  at  time 
of  operation,  from  previous 
hemorrha!,'c. 

No  autopsy. 

21  day«  after  injury,  hem.  40  oz. 
occurred  ;  hem.  w)if!n  ligature 
came  away;  arresti'd  by  com- 
])res»ion,  but  recuircd  fatally. 
No  autopsy.  Tied  beneath  the 
clavicle.  Ciiven  as  subclavian. 
Ball  enti'red  near  lower  edge  of 
clavicle  and  emerged  at  ujiper 
angle  of  scapula;  extensive 
slongh  and  suppuration  ;  did 
■well  for  10  days  aft-r  ligature, 
then  on  ligature  coming  away, 
slight  hem.;  compression.  Au- 
topsy :  Nothing  of  interest. 
(Tied  below  clavicle.  From  di- 
rection and  location  of  wound 
it  is  evident  that  the  subclavian 
was  tied  on  first  rib,  and  very 
likely  in  the  wound  of  entrance 
— Aiiihiir.) 

Three  months  after  injury,  both 
wounds  (of  exit  and  entrance) 
■were  healed;  Feb.  1st,  swell- 
ing in  axilla  began  ;  March  1st, 
there  was  perceptible  fluctua- 
tion, but  no  thrill  ;  March  14, 
profuse  arterial  hemorrhage: 
after  ligature  extreme  prostra- 
tion. "  Reaction  never  fairly 
set  in."  No  autopsy. 
Ball  entered  just  below  clavicle, 
emerging  at  inferior  angle  of 
scapula;  secondary  hemorrhage 
several  times  ;  after  ligature, 
tumor  decreased  very  rapidly  ; 
9th  day,  hemorrhage.  Autopty: 
Ligature  still  on  artery,  and 
clot  on  either  side  ;  no  clot  in 
sac.  (Fatal  hemorrhage  was 
very  probably  from  vessels  com- 
municating with  sac. — Author  ) 
About  one  month  after  injury, 
aneurism  appeared;  after  the 
ligature,  the  sac  was  opened 
and  clot  turned  out,  and  ineffec- 
tual attempts  made  to  secure 
the  bleeding  vessels  ;  tampon 
■was  used.  Autopsy:  Ligature 
was  firmly  tied  aro'ind  artery; 
hem.  had  occurred  through  col- 
lateral circulation  through  sac.) 
Although  axillary  artery  was 
divided,  patient  rode  8  miles, 
closely  pursued  for  3 ;  hem. 
profuse  but  ceased  spontaneous- 
ly ;  did  well,  suffering  only 
slightly  from  aneurismal  swell- 
ing until  2Jd  day.  when  hem. 
took  place,  1  pint ;  3  days  after 
ligature,  erysipelas  ensued;  6th. 
day,  pleuritis;  died  Sth  day. 
Autopsy:  Axillary  vein  and 
artery  cut  in  two  by  ball ;  no 
clot  on  either  side  of  ligature; 
copious  effusion  in  left  pleura  ; 
no  fibrinous  clot  in  aneurismal 
sac  ;  pericarditis. 


200 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Ko. 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operalion. 


o   >, 


Lidell,  Jno.  A., 
1863. 


Med.  Surg.  Hist.  Reb., 
Part  I.,  p.  543^. 


M. 


174 


Coolridge,R.H., 

1863. 


Isaac  Norris,  Jr.,  in 

Med.  Surg.  Hist.  Eeb. 

p.  545. 


177 


179 


Morton,  J.  C, 
1864. 


McLean,  C.  E. 
1863. 


Morton,  T.  G., 
1864. 


McKee,  J.  C. 


Humphrey, 
0.  M. 


Dr.  C.  Wagner  in 

Med.  Surg.  Hist.  Eeb., 

Part  II.,  p.  440. 


Dr.  J.  Hopkinson  in 

Med.  Surg.  Hist.  Reb., 

p.  440. 


Dr.  W.  S.  Hendric  in 

Med.  Surg.  Hist.  Eeb., 

p.  441. 


Med.  Surg.  Hist.  Eeb., 
Part  il.,  p.  468. 


do.  p.  634. 


Mid 


M. 


Aneurism,   shot     23  days 
■w'nd  left  axilla. 


Aneur.,  axillary, 
shot  wound. 


June  21, 
1863. 


June  21. 


67  days. 


June  9 
1863. 


Shot  ;   flesh  w'nd  21  days, 
of  right  arm. 


51  days. 


do. 


Shot  wound  and 
amputation   at 
shoulder-joint. 


Solid  shot  wound 
shoulder-joint ; 
amputation. 


do. 


27  days. 


8  days. 


do. 


do. 


Sept.  30. 
1864. 


July  2, 
1863. 


June  4. 
1864. 


May  28. 


Jan.  30, 
1863. 


Wone 
noted 
as  im- 
mediate 
Doubt- 
less it 
occurd 
66th 
day. 


Oc- 
curred. 


July  23; 
Aug. 
1-23. 


June 
2.')-30  ; 
July  1. 


INNOMINATE    AND    SUBCLAVIAN    ARTE  It  IKS. 


201 


outer  edge  of  Scalenus  Anticus  and  lower  harder  of  First  liib) — continued. 


No. 


Dato  of 
operation. 


174 


176 


July  14, 

li<63. 


24,28,29 


Aug.  17, 
1863. 


Oct.  21, 

1804. 


Aug.  23, 
1863. 


July  1,1864 


178    Sept.  1,1864. 


»H 

)r. 

> 

a 

bo 

E5 

>-. 

J 

a 

T3 

Becovery. 


None. 


gtliday, 


Oc- 
curred 
during 

and 
prob'ly 
after 


Not 
noted. 


Condition. 


Cause  of  death, 
dato  after  op. 


4'ith    day.      Hemor- 
rhage ;    Huppura- 
tiou. 


6  hours.  Hem.  he 
fore  ope' n.  Shock? 
Dyspnoea. 


KEMAUKS. 


31st  day.  Hem.  he- 
fore  op'n  ;  exhaus- 
tion. 


9th  day.    Hem. 


1  hour.    Exhaust'n 
hemorrhage. 


2d  day.     Cause  ? 


20th  day.     Exhaus- 
tion. 


Ball  cnlorod  axilla  from  in  front, 
wounding  a.xillary  artery  and 
Kome  of  hracliial  ple-vun;  hem. 
immediate  to  nyncope  ;  ceaHcd 
spontaneouHly :  lf)th  day  aftpr 
wound,  aneurism  was  noticed, 
MO  thrill:  had  felt  soiriething 
"  give  wiiy"  on  moving  liis  arm; 
21  days  after  wound,  ligature  of 
finbchivian  :  tumur  dimlni^hi'd 
immediately  ;.Tth  day,  xacburst, 
and  on  lliis  and  following  day 
discharged  several  onncs  of 
liloody  pus  ;  18th  day,  ligature 
loose  ;  24th  day,  lirofuso  hem. 
from  sac;  liq.  ferri  pfrrsulph. 
locally  arrested  hern.;  2Sih  and 
29th,  hemorrhage;  4fth,  41st, 
and  42d  days,  suppuration  as- 
sumed very  offensive  character; 
death, 46th  day.  Autopsy  :  Firm 
clot  on  both  sides  of  ligature  ; 
cicatiices  (seeming  y  tubercu- 
lous) on  apices  of  lungs. 
Autopsy:  Large  nerve  included 
in  ligature;  (Patient  had  died 
with  symptoms  of  great  dys- 
pnoea.) (It  is  most  probable  that 
this  nerve  was  the  posterior 
thnrrific,  which  had  been  press- 
ed by  the  aneurism  toward  the 
scalenus.  Simple  ligature  of  a 
cord  of  the  brachial  plexus  go- 
ing to  the  arm  would  not  pro- 
duce such  symptoms  of  dys- 
pnoea. This  last  accident  has 
happened  quite  frequently. — 
Author.) 

Hemorrhage  twelve  days  after 
wound  ;  brachial  tied  ;  9  days 
later,  hemoirhage  again  ;  sub- 
clavian tied  ;  patient  improved 
for  a  while,  but  died  of  exhaus- 
tion 31st  day. 

July  ?:^d,  hem.  from  brachial, 
and  this  vessel  tied  ;  Aug.  2, 
amputation  of  arm  for  hem.; 
Aug.  23,  hem.  from  axillary, 
and  ligature  of  subclavian;  did 
not  do  well,  and  died  from  hem. 
Sept.  1.  Autopsy :  Proximal 
side  of  ligature  c  used  by  clot ; 
hemorrhage  was  distal.  Below 
clavicle. 

Hem.  from  brachial  June  2.i,  and 
axillary  tied  :  June  .^Oth,  hem. 
and  compression;  July  1,  hem. 
from  axillary  at  ligature:  sub- 
clavian tied  ;  lo.st  30  oz.  blood 
in  operation,  and  died  in  one 
hour.  Dr.  W.  P.  Moon  tied  the 
axillary.  Autopsy  not  given. 
Below  clavicle. 

Shot  passed  through  left  axilla 
and  aneurism  resulted  ;  sub- 
clavian tied  at  amputation. 
iCases  Nos.  17S  to  184.  inclusive, 
were  most  likely  ligatured  be- 
neath the  clavicle. — Author.) 
Kight  arm  torn  off  by  shot  ;  pro- 
fuse hem.:  immediate  amputa- 
tion by  Dr.  G.  C.  Harlan:  7 
days  later,  profuse  hem.;  Feb. 
7,  lig.  of  subclavian,  by  Dr. 
Humphrey. 


202  PRIZE    ESSAY. 

Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


u- 

o 

V.  1=1 

^  6 

o  >, 

"■2  =1 

o3   03 

<D    2 

3  " 

Aho 

ft. 2 

fi 

13 

Hasson,  A.  B. 


Morton,  J.  C. 


Day,  W.  E., 

1S64. 


Howard,  B., 

1863. 
Levis,  R.  J. 


Med.  Snrg.  Hist.  Eeb., 
Part  II.,  p.  635. 


do.  p.  64.3. 

do.  p.  648. 
do.  Part  I.,  p.  42  3. 

do.  p.? 
do.  Part  II.,  p.  716. 


Morton,  J.  C, 
1864. 


Wagner,  C. 
1864. 


Oakes,  T.  P., 
1864. 

Otis,  G.  A., 
1862. 


Uuknown,  1862, 

do. 

do.  1863. 

do.  1864. 

Humphrey, 
0.  M.,  1864. 


M. 


Mid 
age. 


M.     27 
M.     21 


do.  p.  545. 

do.  p.  6.50. 

do.  p.  536. 
do.  p.  760. 


Med.  Surg.  Hist.  Reb., 
by  Dr.  H.  L.  Tliomas. 
Med.  Surg.  Hist.  Reb. 


do. 


Am.  Med.  Times,  vol. 
vii.,  p.  161,  1864. 


After  amputation 
at  shoulder- joint 


Amputation   at 
shoulder-joint. 


Hem.  axilla  ;  shot 
wound  humerus 
and  scapula. 

Shot  wound  root 
of  neck. 


Shot   wound    of 
humerus. 

Shot  wound   left 
arm  ;    amputa- 
tion. 


Secondary  hemor- 
rhage after  exci- 
sion of  humerus 
for  shot  fracture. 

Hemorrhage  from 
axillary   after 
excision   of  hu- 
merus. 

Excision   after 
shot  fracture   of 
humeruK. 

Amputation  of 
upper  3d  after 
shot   wound   of 
humerus(hem.?) 

Shot  wound  left 
shoulder. 

Shot  wound  of 
humerus, 
do. 


Crush   of  arm 
(railroad  acci- 
dent). 


36  days, 


43  days. 


A  few 
hours. 

10  days. 


8  days. 


3d  divi- 
sion. 


do. 


do. 


3d  divi- 
sion. 


do. 


June  15, 
1864. 


Sept.  17, 
1862. 


Aug.  16, 
1864. 


Oct.  6, 

1864. 


July  13; 

Aug. 
5,  6. 


Dec.  14. 


May  3,        Oc- 

1863.  curred. 
JunelS,  July  25; 

1864.  Aug.  8. 


do. 


do. 
do. 


Aug.  16 
1864. 


Oct.  8, 
1864. 


July  .30, 
1864. 

M'chl4, 
1862. 


May  31, 
1S62. 


Jan.  11 
1863. 


July  14, 
186 


Sept.21. 


Nov.  21. 


Oc- 
curred. 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES. 


203 


outer  edge  of  Scalenus  Anticiis  and  lower  border  of  First  Rib) — continued. 


No. 


Datn  of 
opei'iitiou. 


ISO    Aug.  6,1864. 


Sept.  27, 
ISliii. 


Sept.  26, 
lt)04. 

Dec.  ]4, 

1864. 


May  or 

Jane,y  1863, 

Au!j.  S, 

1864. 


W 


4j   •  p< 

a  o  o 


Not 
giveu 
if  it  oc. 
cunod 


Sept.  21, 
1864. 


Nov.  21, 
1864. 


July  30, 
1S64. 


Marcli  24, 
1862. 


June  7,1862. 

Aug.  1862. 

Jan.  12, 
186.3. 

Soon  after. 


Not 
noted. 


Recovery. 


Kecovered. 


Be- 
fore 


Condition. 


Cured,  am- 
putation at 
slioulder. 


Recovered.       Cured 


Recovered. 


Cause  of  death, 
date  after  op. 


RE.MAKKS. 


11th  day.     Exhaus- 
tion. 


Few  hours.  Exhaus- 
tion; gangrene. 


4th  day.  1 


July  18th.  Exhaus- 
tion. 


Cured. 


2d  day.     Not  given, 
E.xhaustion. 


6th  day.  Exhaus'n, 


9th  day.   Exhaus'n. 


22d  day.  Pyajmia. 
(April  loth.) 


11th  day.    (Exhaus- 
tion?) 
Died. 


Amputation    at    «lion1dcr,   June 

lo,  for  shell   wound;  July  Vi, 

liein.  ;    axillary     artery     tied  ; 

hem.   ai;ain,  Aug.  .Otli  and  <Jth  ; 

dealh,  Aug.  ITth".  1864. 
Fracture  of  liumerus,  Sept.  17; 

hall  extracted,  Sept.  2;S  ;  Sept. 

26,  hemorrhage  from  sloughing; 

gangrene  ;  died  few  hours  after 

la.-it  ligature. 
Dr.  J.  E.  Chesely  amputated  the 

arm  on  same  day. 

Ball  passed  through  neck  at 
outer  edge  of  left  stcrno-mas- 
toideus,  ahout  2  inches  above 
clavicle. 

Humcrns  was  amputated  at  up- 
pi>r  third. 

Amputation  at  upper  3d,  on  June 
18;  (?)  hemorrhage  from  and 
ligature  of  axillary  July  2.ith, 
by  Dr.  G.  B.  Boyd  ;  Aug.  8th, 
hemorrhage  from  ligature,  and 
ligature  of  subclavian  over  1st 
rib ;  hem.  again  on  7th  day, 
controlled  by  pressure;  (Dr.  T. 
H.  Squire  amputated  arm;)  af- 
ter ligature  of  suhilavian.  iire.s- 
sure  was  continued  for  6  weeks. 

Shot  fracture  head  of  left  hu- 
merus, much  destruction  of  tis- 
sues. 

After  excision,  arm  amputated 
at  shoulder,  by  Dr.  J.  (!.  Jlor- 
ton  ;  10  days  later,  hemorrhage 
and  ligature  of  subclavian. 


Ball  wounded  spinal  cord,  cans 
ing  paralysis. 


29th  day.     Exhaus-  Arm  amputated  at  middle  third  ; 
tion.  hemorrhage  recurred  and  liga- 

ture of  subclavian. 
Died  Aug.  30,  1864. 


January  17,  amputation  at  upper 
third  humerus;  6  days  later, 
hemorrhage  ;  7th,  do.:  14th.  do. 
profuse  ;  Feb.  1,  ligature  of  sub- 
claviau  ;  no  unfavorable  symp- 
toms except  slight  surgical 
fever.  I  infer  that  this  case 
will  appear  in  the  3d  ^^urgical 
volume  of  tlie  Jled.  aud  Surg. 
History,  as  Dr.  Otis  has  given 
one  case  by  Dr.  H.  from  same 
source. 


204  PRIZE    ESSAY. 

Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
opecator. 


Source  of 
information. 


Cause  of 
operation. 


g   03 

a 


196 

do 

198 
199 

do 
do 
do 

iiUU 
201 

do 
do 

204 


Uuknown. 


Med.  Surg.  Hist.  Reb. 


do. 

M 

do. 

M 

do. 

M 

do. 

M 

do. 

M 

do. 

M 

Thiersch,  1865. 


Arch.  Kliu.  Chir. 
Bd.  X.  p.  236. 


Busch,  W. 


do.  1865. 


Church,  W.  H. 
1865. 


do.  p.  237. 


do.  p.  236. 


do.  p.  241. 


Dr.  H.  G.  Piffard  in 

Am.  Jr.  Med.  Sci., 

Oct.  1865,  p.  393. 


M. 


Subclav.  axillary 
aneurism  (punc- 
tured wound). 


Hemorrhage  after 
opening  abscess 
of  axilla. 


Hemorr'ge   (after 
punctured  w'd). 


Shot  wound  of 
axilla. 


Suicidal  shot  w'd 
of  axilla. 


9  days. 


3d  divi- 
sion. 


Imme- 
diate, 
and 
Jan.  16. 


23  days. 


July  3. 


June  3, 
1865. 


June  3, 
slight ; 
June  13, 
profuse. 


INNOMINATE    AND    SUBCLAVIAN    ARTKItlEB. 


205 


outer  edge  of  Scalenus  Antious  and  lower  border  of  First  Rib) — continued. 


No. 


Date  of 
oporaliou 


? 

■2  r^  ° 

fc.      --      t^ 

ase 

.Si'is^ 

OJ  o  d 

H 

-a 

196 
197 
198 
199 
200 
201 


202 


Recovery 


Condition. 


CauHe  of  death, 
date  after  op. 


Jan.  17, 

1865. 


204 


203 


17th- 

29th 

Jan'y. 


Unknown. 


Sept  11, 
188.3. 


July  26, 
1S66. 

June  13, 
1865. 


Died. 


Recovered. 
Recoveied. 
Recovered. 


Oc- 
curred. 


Oc 
cuired. 


Recovered 


Cured. 


do. 
do. 
do. 


14th  day.     Pysemia; 
hemorrhage. 


6th  day.     Pysemia. 


11th  day.    Pyamia; 
hemorrhage. 


At  the  foot  of  page  .047,  of  IhI 
unvi^.  vuluDio  of  hiH  ma>.'niflcent 
bintory.  Dr.  G.  A.  OtiH  wayw  :  ''  I 
shall  ('nuincrate  a  total  of  .02 
cases  of  ligature  of  the  subcla- 
vian (in  a  future  volume)  with 
41  deaths."  I  have  been  able  to 
And,  and  have  given  lieretoforo 
(Iroiu  the  1st  and  2d  voluniei, 
4.')  cases,  37  of  which  were  fatal. 
There  is  left  to  be  reca|iitulated 
in  the  3d  volume,  an  additional 
nuiiiber  of  7  cases,  of  which 
4  (_|_;^7  =  41)  were  tatal,  and  3 
recovered.  I  have  (in  order  to 
be  as  exact  as  possible)  included 
Dr.  O.  M.  Humphrey's  case,  as  I 
am  sure  Dr.  Otis  will  have  this 
case  in  the  3d  volume.  1  could 
not  obtain  from  the  Surgeon- 
General's  office  advance  copies 
of  these  cases,  on  account  of  the 
labor  requisite  to  hunt  them 
out  in  advance.  I  am  under 
many  obligations  to  Dr.  Otis 
for  prompt  answers  to  inquiries 
and  otlier  courtesies. — Author. 


In  this  category  I  might  include 
4  fatal  cases  of  ligature  of  sub- 
clavian for  shot  wounds,  by 
Hopkiuson,  Wells,  Kennedy, 
and  Andersou,  given  by  Prof. 
T.  G.  Morton,  in  Am.  Journal 
Med.  Sci.,  July,  1867.  These 
are  doubtless  included  by  Dr. 
Otis  in  the  above  .02  cases,  and  I 
have  so  considered  tliem  rather 
than  incur  the  risk  of  counting 
them  twice. 

4th  and  oth  days,  symptoms  of 
pneumonia  ;  6th  and  7th.  rigors 
and  pysemic  symptoms  ;  uafa- 
vorable  couditions  increased,  a 
diarrhoea  occurred,  and  death 
on  14th  day.  The  ligature  of 
the  subclavian  did  not  arrest 
the  hem.  completely,  and  ope- 
rator could  not  tie  bleeding 
vessels  in  wound  on  that  ac- 
count. 

Patient  was  in  6th  week  of  a 
spell  of  low  fever,  and  was 
consequently  much  exhausted. 
Abscesses  in  various  parts  of 
body. 

Gangrene  of  forearm  just  before 
death  ;  numerous  abscesses  in 
lungs  ;  artery  firmly  closed  on 
botli  si'fes  of  ligniure  ;  both 
axillary  artery  and  vein  wound- 
ed, the  "latter  most  so. 

Arm  slightly  paralyzed  from  in- 
jury to  nerves  by  missile. 


3d  day.  Exhaust'n  ;1  Before  operation,  hemorrhage  16 
hem.;  gangrene.  oz.  ;  3d  day,  do.  6  oz.  Autopsy: 
Axillary  wounded  in  2d  divi- 
sion ;  diffuse  aneurism ;  gan- 
grene of  arm  (slight). 


206 


PEIZE     ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
operator. 


Source  of 
infoimation. 


Cause  of 
operation. 


C   33 


>«  bo 


207 


210 
211 

212 

213 


215 

216 
217 

218 

219 

220 
221 


223 


Schauerburg, 

isee. 


Asch,  1S66. 


Demme,  Sr. 
Forster. 

'  Chassaignac. 

do. 


Arch.  Klin.  Chir. 
Bd.  X.  p.  236. 


Schmidt  Jahrbuch., 
Bd.  xcvli.  p.  3il,  1858. 


Arch.  Klin.  Chir. 

(cit.),  p.  237. 

do. 


Chassaignac  traits 

Clin,  et  Pratique, 

Paris,  1S61,  t.  i.  p.  316. 

do. 


Lannelongue, 
Bordeaux. 


Legouest. 

Middeldorpf. 
N^laton. 

Pelican. 

Nussbaum. 

do. 
do. 


O'Reilly, 
Dublin. 


Pirogoff. 


Schmidt  Jahrbuch., 
Bd.  cxv.,  1862,  p.  376, 


Legouest  Chir. 

d'armee,  1863,  p.  421; 

Arch.  Klin.  Chir., 

(cit.),  p.  238. 

Arch.  Kliu.  Chir., 

(cit.),  p.  238. 

Schmidt  Jahrbuch., 

1856,  Bd.  Ixxxix.  p. 

225 

Arch.  Klin.  Chir., 

Bd.  X.  p.  239. 

Arch.  Klin.  Chir., 
Bd.  X.,  1869,  p.  238. 


do. 


Cyclop,  of  Anat. 

Phys.,  vol.  iv.  p. 

616-17. 


Arch.  Klin.  Chir. 

(cit.);  Pirogoff's 

Military  Surgery, 

p.  4-19. 


M.  iSol-    R. 
dier 


Sol- 
dier 


M. 


M. 


M.  I  Sol 
dier 


Sol- 
dier 


Sol 
dier 


Hemorrhage  (shot 
wound  slioulder- 
joint  fracture). 


Axillary  aneur. 
(shot  wound). 

Subclav.  axillary 
aneurism. 


Punctured  wound 
of  axilla. 

Hemorrhage  after 
excision  of  hu- 
merus. 

Hemorr'ge  (after 
division  of  cica- 
tricial  contrac- 
tions in  axilla?). 


Aneurism  of  ax- 
illary (traumat- 
ic). 


Hemorrhage   (re- 
section of  hu- 
merus). 


Aneurism  (sub- 
glenoid disloca- 
tion). 

Hemorr'ge   (after 
disarticulation 
of  humerus). 

Hem.  during  rem. 
cancerous  tumor 
of  axilla. 

Hem.  punctured 
wound  axilla. 

Immense  tumor 
of  axilla. 


Diffuse  aneurism 


Hemorr'ge  (after 
ligature  of  bra- 
chial for  traum. 
aneurism). 


3d  divi- 
sion. 


do. 

do. 
do. 

do. 

do. 


do. 


3d  divi- 
sion. 


Pro- 
fuse.. 


Occur"  d 
often. 


Often. 


I  N  N  O  M  I  N  A  T  K    AND    S  U  ]1  C  L  A  V I  A  N     A  K'l'  K  li  I  JO  S . 


207 


outer  edge  of  Scalenus  Anticus  arid  lower  border  of  Fir d  Rib) — continued. 


No. 

Dato  of 
operatiou. 

t1      (H      1^ 

o  ci  3 

OJ  o   c« 

w 

-a 

RESULT. 

REMARKS. 

Recovery. 

Condition. 

Cause  of  death, 
dato  after  op. 

207 

July,  ISGC, 

1S66. 
? 

? 
? 

r      ? 
? 

? 

? 

? 
? 

? 

? 

? 
? 

1833. 
7 

2d    day.     Pnenmo- 
tliora.v  ;    pneumo- 
nia. 

Ilomorrhage. 

22d    day.      Hemor- 
rhage; pneumonia. 

8th  day.   Gangrene. 

Panctiire  of  pleura  dnring  pas- 
sage of  noodle  aroiiml  Hrtory; 
violent  influx  of  air  to  pleural 
cavity.     AiitopHy:    Right   lung 
coniplotoly  collapsed  and  proH--- 
ed    against   vortoliral    column  ; 
pleiiritis  ;     pneumonia    of    left 
lung. 

208 

Oc- 
currod. 

13,  14 

209 

Pneumonia    accompanied    with 
cough  Hupervonod  and    homor- 
rhage  occurred  l.'Uh   and    J  4th 
days  after  operation.   Auto)>.sy  : 
Pneumonia;  rupture  of  artery 
at  seat  of  ligature. 

210 

Recovered. 

Cured. 

211 

None. 

Did   well   until  4th  day,  when 
gangrene  ensued,  causing  death 
on  8th  day. 

212 

One 
I'ecovered. 

Cured. 

213 

One  died. 

Died. 

Pyasniia. 

Several  days.  Hem. 

Died. 
Died. 

concerning  these  two  cases  than 
this  short  extract  in  Chassaig- 
nac's  work  cited-    "Deux  lois 

2U 

j'ai   pratique  la  ligature  de  la 
soiis-claviere ;    une    fois    avec 
succes    chez    un    malade    qui 
avoit  subi  le  disarticulation  de 
I'epaule   suivie   d'hemorrhagie 
consecutive.      Une    autre   fois 
chez   un  homrae   qui   apres   la 
section   d'uu  bride  inondulaire 
de  I'aisselle  a  volt  en  des  henior- 
rhagies  recidivtes." — {Author.) 
(1  could  not  obtain  the  Journal 
de  Bordeaux,  where  a  full  ac- 
count  of    this    case    is    given. 
The  Jn.hrbv.ch  only  contains  an- 
nouncement.— author.) 

215 

Once. 

Recovered. 

Cured. 

217 

Once. 

Rupture  of  sac  ;  death.     Autop- 
sy :    Arteria    dorsalis    scapulse 
opened  into  sac. 

1^1  S 

219 

Recovered. 
Recovered. 

Cured.    ? 
Cured. 

?,?0 

?!?1 

(Dr.  Wilhelm  Koch  gives  this  as 
a   fatal    case.     Kusbaum    says 
the  operation   was    unauccess- 
fnl.     As  the  probability  is  that 
Dr.  N.  lold  Prof.  Gurlt   it  was 
fatal   (see   Archiv),   I   have  so 
marked  it. — Atithoi-.) 
Thrown  by  runaway  horse   dis- 
location of  shoulder;  reduction; 
aneurism  appeared  (due  to  in- 
jury by  fall  or  reduction?);  4th 
and"  6th  fingers  were  destroyed 
by  gangrene. 

222 

Recovered. 
Recovered. 

Cured  (lost 
two  fin- 
gers.) 

Cured. 

223 

208 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  [between 


Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

Pi    m 
.2   ^ 

Hi 

^   bo 

'A 

IB 

m 

6 
be 
< 

03  0 

fi  a 

■",-( 

Pirogoff. 

do. 
do. 

Broca,  1862. 

Seyppel,  1880. 

Langenbeck. 
Graf,  E.,  18a6. 

Holthouse,1864. 
Pereira,  1826. 

Vianna,  1S45. 

Almeida,  1846. 

Texeira,  1847. 
Barbosa,  1832. 

Bryant,  Thos. 

Biirt,  W.  (On- 
tario), 1873. 

Bennett,  E.  P. 
(Conn.),  1867. 

Butcher. 
Busch,  F.,  1872. 

Bickers  teth, 

1864. 

Cledoux,  1875  ? 

(Navorreux). 

Arch.  Kliu.  Chir. 

(cit.);  Pirogoif's 

Military  Surgery 

p.  449. 

Surg.  Anat.  Arteries. 

do. 

Military  Surgery. 

Lancet,  July  2,  1870, 
p.  11. 

Arch.  Klin.  Chir., 
(cit.),  p.  241. 

do. 
do.  p.  242. 

do. 

Arch.  Klin.  Chir., 

(cit.);  Journ.  Med. 

Soc,  Lisbou,  1862, 

p.  .S86. 

do. 

do. 

do. 

do. 

System  of  Surgery, 
Phila.,  1873,  p.  204. 

N.  Y.  Med.  Jr.,  Oct. 
1873. 

N.  Y.  Med.  Record, 
Nov.  1837. 

Schmidt  Jahrbuch., 

Bd.  cxxxiv.  S.  359. 

Archiv  fur  Klin, 

Chir.,  Bd.  xv.  p.  475. 

T.  Holmes  in  Lancet, 

1872,  vol.  ii.  p.  37. 

Gaz.  Ae^  Hop.,  1876, 

p.  237. 

M. 

M. 
M. 

Sol- 
dier 

Mid 

age 
Sol. 
dier 

E. 
R. 

L. 

Hemorr'ge  (after 
liirature   of   bra- 
chial for  traum. 
aneurism). 

Malignant  tumor 
of  axilla. 

Hemorrhage   shot 
wound   subclav. 
axillary. 

Innominate  aneu- 
rism. 

Axillary  aneur. 
after  punctured 
wound. 

? 
Hemorrhage  after 
ulceration  arm. 

Aneurism   (trau- 
matic). 
Axillary  anetir. 

do. 

do. 

do. 
do. 

Innominate  aneu- 
rism. 

Hemorrhage  after 
amputation    of 
shoulder. 

Pulsating   tumor 
of  axilla  in  hu- 
meral region. 

Aneurism. 

Wound   axillary 
(fracture   of  hu- 
merus). 

Aneurism  of  aorta 
and  innominate. 

Aneurism,  axilla- 
ry   (gored    by   a 
cow). 

3d  divi- 
sion. 

'>,'>?> 

'>p,f, 

9.91 

13  days. 
10  days. 

3d  divi- 
sion. 

do. 

do. 
do. 

do. 
do. 

do. 

do. 

do. 
do. 

do. 
do. 

do. 

do. 
do. 

do. 
do. 

mR 

M. 

24 

Wt 

9M 

M. 

M. 

M. 

M. 

M. 

M. 
M. 

M. 
M. 

M. 

M. 
M. 

32 

33 

37 

51 

41 

50 
41 

33 
35 

30 

42 
43 

E. 

7 

L. 

R. 

E. 

L. 
L. 

E. 
L. 

? 

E. 

231 

9:n 



Before. 

9,SS 

9M 

93n 

9,Sfi 

1^37 

238 
939 

Often. 

940 

241 

9,49, 

Oct.  7. 

14,15, 
23,  24. 

243 

M. 

32 

L. 

INNOMINATE    AND    SUBCLAVIAN    AIlTEIilES.  209 

Older  edge  of  Scalenus  Anlicus  and  lower  border  of  First  Itib) — continued. 


Dato  of 
opoi'iitioii. 


O    P   CJ 
*  O  1« 


Sept.  30, 
181)0. 


Feb.  10, 
1826. 


Mar.  184'). 

Oct.  28, 

1S46. 

1S47. 

April  2, 

1862. 

Aug.  1871. 


July  1873. 


239  1867. 


Oct.  24, 
1S72. 


Oc- 
curred 


Oc- 
cun-ed. 


3-13. 


Oc- 
curred, 


None? 


1864? 

l&l^.         Slight. 


14 


Recovery.     Condition. 


Cause  of  death, 
date  after  op. 


IlKMARKS. 


Recovered, 


Recovered. 


Recovered. 


Recovered 


Recovered. 


Improved  I 
Cured? 


Cured. 


Cured. 


Cured. 


Cured. 


Cured. 
Improved. 


Cured. 


Not  cured. 


Recovered 


Cured. 


Hemorrhage. 

6th  day.     Thlolatis. 
Hem.;  pyajmia. 


13th  day.     Hem. 


16th  day.     Hem. 


Died.  Several  days. 


7th    day.     Exhaus 
tion  (pysemia?). 


21st  day. 
tion. 


SufFoca- 


Patient  died  a  good  while  after 
operation,  of  pulmonary  v;a.n- 
grene.  The  rarotid  artery, which 
was  not  tied  liecauKe  thi;re  wa» 
no  pulsation  in  it,  was  found  at 
autoppy  to  bo  pervinuH,  though 
mncii  diminished  in  calihre. 

Nov.  17,  patient  was  stabhcd  in 
an  affray  ;  hem.  and  marked 
infiltration  of  a.xilla  ;  24th  Nov. 
puncture  of  abscns.'*,  severe  ar- 
terial Iiem.  and  lii/ature  of  sub- 
clavian.    Recovered  slowly. 

6  weeks  after  fracture  of  fore- 
arm, amputation  of  upper  third 
humerus ;  2  weeks  later  the 
stump  became  greatly  infiltrat- 
ed and  swollen,  and  was  punc- 
tured ;  profuse  hem.  resulted, 
and  littature  of  subclavian. 
Recovered  within  a  yeai-. 

Suppuration  and  rupture  of  sac 
just  before  ligatuie. 

This  patient  recovered  in  40 
days. 


Recovered  in  50  days. 


Patient  still  living.  Rapid  con- 
valescence followed,  witli  great 
dimioutioa  and  consolidation  of 
the  aneurism. 

Drunk  ;  run  over  by  locomotive, 
crushing  both  arms.  Right, 
amputated  middle  3d  forearm  ; 
left,  at  shoulder-joint.  Hera- 
orrliage  profuse.  Ligature  of 
subclavian. 

Tumor  ceased  to  grow,  but  did 
not  decrease  in  size  as  result  of 
operation.  Probably  connected 
with  exostosis. 


Transfusion  after  ligature  imme- 
diately. Autopsy:  Lungs  ge- 
latinous. (Query:  Carcinoma 
or  infarction?)  Pus  in  medias- 
tinum. 

Carotid  had  been  tied  7  weeks 
previously. 

Hemorrhage,  immediately  after 
accident,  was  arrested  by  tam- 
pon. Several  days  after,  aneu- 
rism appeared.  Slight  hemor- 
rhage after  operat'on,  arrested 
by  compress. 


210  PRIZE    ESSAY. 

Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
operutor. 


Source  of 
information. 


Cause  of 
operation. 


<f-< 

o 

=«  d 

a  o 

c  ,2 

oi   cS 

•gM 

3  " 

f^% 

ft 

■a 

fi§ 


245 

246 


Le  Dentn, 

lS7«-7. 


Duplay,  1874. 
Durham.  ? 


Eliot,  Prof.  J., 
1S76. 


Am.  Jr.  Med.  Sci., 
July,  1S77,  p.  270. 


Gaz.  Hebdora.,  Oct.  15 

1S75,  p.  669. 

Lancet,  1S72,  p  37. 


Am.  Jr.  Med.  Sci., 
April,  1877. 


Wound  axillary 
(dislocation  of 
humerus). 


j  Knife   wound   of 

axilla. 

R.  'Aneurism  of  in- 
nominate. 


3  day  S.I  3d  divi 
.sion. 


3  years 


do. 
do. 


do. 


INNOMINATE    AND    SUBCLAVIAN    ARTERIKS. 


211 


outer  edge  of  Scalenus  Anticus  aud  lower  border  of  First  Rib) — continued. 


No. 


244 


24.'5 
246 


Date  of 

t^  ^  p 

|J1    M    os' 

operation. 

5  0  tt) 
11^ 

W 

'O 

Recovery. 


Condition. 


Cause  of  death, 
date  after  op. 


REMARKS. 


1S74. 
? 


Oct.  15, 

1S76. 


5  daya. 
None. 


16,  22. 


Next  day.    ExliauH- 
tlon. 


;jth  day.    Hem. 
6th  day.     Shock. 


25th    day.     Hemor- 
rhage; exhaustion. 


Amputation  at  glioulder  Hlinal- 
taneously.  Autophy:  Aorllc 
valves  athoromatouH  ;  fatty 
liver;  rupture  of  axillary  at 
origin  of  suhscapularis.  M. 
Patias  rfmarks:  "In  all  pub- 
lished c'AK'M  rupture  had  oc- 
curred at  this  ])0Jiit." 

Fever  supervened. 

Carotid  tied  simultaneously. 
Subclavian  tied  first,  and  pul- 
sation (ceased  in  turnor),  or 
■was  affected  by  ligature  of  this 
vessel. 

Carotid  lif,'atured  simultaneous- 
ly.  After  operation  patient  did 
well  with  exception  of  slight 
cough  and  difficult  deglutition. 
Digitalis,  iodide  or  bromide  of 
potas.,  prescribed  as  indicated 
by  symptoms.  6tli  day,  wounds 
dischargiug  small  quantity  pus. 
7th  and  8th  days  a  little  rest- 
less. 9th,  Kith,  11th,  better. 
12th,  13th,  coughs  a  great  deal, 
ulceration  increasing  ;  potas. 
lodid.  substituted  for  bromide. 
16th  day,  got  up  and  dressed 
himself,  quite  comfortable, went 
to  water-closet,  sac  ruptured, 
arterial  hemorrhage  16  ounces. 
Compress  of  lint  saturated  with 
Monsel's  solution  3vj.;  Mon- 
eel's  solution  Injected  into  sac  ; 
same  day,  Svijss  more  injected. 
18th  day,  carried  home;  ligature 
came  away  ;  no  hemorrhage. 
20th  day,  slightly  delirious  ;  3j 
U.  S.  sol.  morphia  every  3  h'rs. 
22d  day,  sac  opened  and  dis- 
charged clot  of  blood  size  of  3 
fingers ;  later  hemorrhage,  a 
pint.  2oth  day,  died.  Autopsy: 
Aorta  atheromatous  ;  mouth  of 
innominate  2  inches  in  diame- 
ter; aneurism,  anterior  aspect 
of  innom.  ;  sac  vertically  .5| 
inches,  transversely  4,  aniero- 
post  3  and  five-sixteenths  inch- 
es. Coagulum  extending  into 
subclavian  and  earoiid.  Loss 
of  blood  by  external  hemor- 
rhage, 38  ounces.  Clot  in  sac 
(equivalent  in  blood),  5  lbs.  13 
ounces.  Total  loss,  S/6«.  3 oun- 
ce* =  cause  of  death.  Prof. 
Antisell  estimates  blood  re- 
maining in  body  1  lb.  13  ounces. 
(The  author  is  indebted  to  Dr. 
h.  A.  Otis  for  a  beautiful  pho- 
tograph of  this  very  interesting 
case  from  the  Surgeon  General'.'! 
office,  and  for  other  kindnesses 
connected  with  this  essay.) 


212 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


o  .2 

o  -^ 


ft? 


251 

252 


Ensor,  F.,  1874,  Lancet,  1875  ;  Am.  Ji-. 
South  Africa.     Med.  Sci.,  April,  1875. 


Farquharson, 
R.  .J.,  1876. 


Fergnsson,  Sir 
Wm.,  1S71. 


do.  1872. 


Farrand,  D.  0. 


Am.  Jr.  Med.  Sci. 
April,  1877. 


Lancet,  March,  1S71 ; 
Am.  Jr.,  July,  1871. 

Med.  Times  &  Gaz., 
1871. 

Lancet,  1S72. 


Detroit  Rev.  Med.  & 

Pharm.;  N.  Y.  Med. 

Record,  Oct.  1866. 


R. 


Aneurism  of  aorta 
and  innominate. 


3d  divi- 
sion. 


Axillary  aneu- 
rism. 


1  year. 


Axillary  aneu- 
rism   (thrust  of 
pitchforli). 

Subclavian  aneu- 
rism. 


Axillary  aneu 
rism  (rebound  of 
cannon). 


do. 


do. 


do. 

(Close 

to  scale 

nns.) 

do. 


INNOMINATE    AND    SUBCLAVIAN    ARTEllIES. 


2U 


outer  edge  of  Scalenus  Anticus  and  lower  border  of  First  Itib) — continued. 


Dato  of 
oi)oratiou. 


U   u,   o 

u  Z  u 

W 

Recovery. 


Coudition. 


Cause  of  death, 
date  after  op. 


REMARKS. 


250 
251 
252 


Sept.  S, 
1«74. 


Sept.  28, 
1876. 


Feb.  1S71. 


April  11, 

1871. 


40,  53, 

Ot,  .'58, 

03. 


Oc- 
curred, 


43  (re- 
mov- 
ed.) 


22 


65th  day.  PlcuritlH;  Patient  wa«  a  Hottnntot.    Caret- 


hemorrliagc. 


62d    day.     Exhaua- 
tioa;  hem. 


ISth  day.    Py£Bmia. 


Died.     (?) 


42d  day.    Hem, 


id  tied  HiiniiltancoiiHly.  Silk 
lijjatiire.  Plouritis  from  reck- 
leHHCxpoBiiroon  part  of  patient. 
Autopny :  Inflammation  of  pleu- 
ra ;  sac  ruptured  just  below  Beat 
of  carotid  ligature,  i'.  S. — Oct. 
24th,  Hllght  hemorrhage  from 
carotid.  Oct.  31,  fever,  cough, 
and  free  hemorrhage  from  the 
carotid.  Nov.  1st,  do.  Nov.  .5th, 
do.  Nov.  9th,  cornea  gave  way 
(ulceration),  and  leu,s  and  vitre- 
ous humorescaped.  Ffice.drawn 
to  left  Kida  sligldly.  Nov.  lOth, 
hemorrhage  again.  Died  Nov. 
12,  comatose.  Suhclavian  was 
closed  firmly.  Pericardium  full 
of  fluid. 

On  20th  day  after  operation,  sac 
ruptured.  36lh,  hemorrhage  one 
quart.  46th,  ligature  removed. 
48th,  agaia  hemorrhage.  62d 
day,  death.  Autopsy :  Trne  an- 
eurism of  axillary  IJ  inch  iu 
length.  Diffuse  sac  filling  en- 
tire axilla.  Incipient  aneurism 
of  inaominate  at  origin.  Aortic 
arch  atheromatous. 

Pressure  of  aneurism  on  bra- 
chial plexus  has  caused  "wrist- 
drop." 

External  jugular  vein  was  tied 
a?   precaution  against    hemor- 


After  operation  a  whitish  fluid 
was  seen  in  bottom  of  wound  ; 
was  thought  to  have  been,  tho- 
racic duct. 

Ligature  J  inch  outside  scalenus. 
Pulsation  in  tumor  and  wrist 
ceased  immediately  after  opera- 
tion, but  returnf  d  in  a  lew  min- 
utes, and  could  be  felt  |  inch 
below  ligature.  2d  ligature  # 
inch  lower,  and  pulsation  ar- 
rested. Hemorrhn ge  tons  frorti 
distal  end.  "  One  thing  was 
found  which  mystified  us  not  a 
little  ;  the  thyroid  axis  was  ab- 
sent. That  it  had  been  present, 
was  easy  of  demonstrition,  as 
the  cicatrix  was  plain.  Verte- 
bral, int.  mam.,  sup.  iutercost.. 
were  found."  (I  am  of  the 
opinion  that  this  was  one  of  the 
not  infrequent  anomalies  givea 
in  the  notes  of  the  52  dissections 
accompanying  this  paper.  There 
was  no  a.-ris.  Inf.  thyroid  from 
innominate.  Trans,  colli  and 
sup.  scapular  from  usual  origin 
of  axis.  Posterior  scapular 
from  3d  division  and  beyond 
ligature.  Ihe  pulsation  noticed 
was  felt  as  soon  as  the  collateral 
route  through  anastomosis  of 
suprascapular  and  trans,  colli 
with  the  posterior  scapular  was 
established,  and  ceased  when 
the  ligature  was  applied  beyond 
this  last  vessel. — Author.) 


214 


PRIZE    ESSAY, 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  {betiueen 


No. 

Name  of 
operator. 

Source  of 
information. 

PATIENT. 

Cause  of 
operation. 

o 

O   * 

o  t*. 

CO 

CO 

?S4 

Furner,  E.  J., 
1866. 

Lancet,  May  2,  1868. 

M. 

30 

K. 

Axillary  aneu- 
rism. 

3d  divi- 
sion. 

KC) 

Fearn,  1838. 

Norris  Contributions, 
Phila.,  1873,  p.  262. 

F. 

30 

R. 

Innominate  aneu- 
rism. 

do. 

•"ifi 

Gartner,  1869- 
70  (Stuttgart). 

Holmes,  T., 
1870.  ? 

Schmidt  Jahrhuch., 
No.  150,  p.  301. 

Lancet,  1872. 

Axillary  aneu- 
rism  (reduction 
of  shoulder). 

do. 
do. 

fM 

M. 

50 

E. 

rism. 

o'lS 

Hughes,  A.  H. 
1872. 

Canada  Lancet,  1873  ; 

Am.  Jr.  Med.  Sci., 

April,  1873. 

M. 

25 

Axillary   aneu- 
rism. 

do. 

'fiq 

Heath,  Christo- 
pher, 1865. 

Lancet,  1868,  and 
July  2,  1870. 

F. 

30 

R. 

Innominate  aneu- 
rism (supposed). 

4mos. 

do. 

^fiO 

Hodges,  1868. 

Bost.  Med.  Surg.  Jr., 
Aug.  6,  1868. 

M. 

35 

E. 

Innominate  aneu- 
rism. 

'>fi} 

Lane,  James, 
1871. 

Lancet,  Jan.  13,  1872. 

F. 

40 

E. 

do. 

5  mos. 

3d  divi- 
sion. 

w, 

Lang,  Ed.,  1873. 

Wien.  Medizin.Woch., 
1874,  p.  770. 

M. 

19 

E. 

Hem.  (fracture  of 
OS  humeri ;  hem. 
after  resection). 

do. 

do. 

9m 

Morton,  T.  G., 
1868. 

Am.  Jr.  Med.  Sci., 
July,  1876. 

M. 

37 

E. 

Crushed  shoulder 
(railroad  acci- 
dent). 

A  few 
hours. 

do. 

INNOMINATE    AND    SUBCLAVIAN    ARTERIES. 


215 


outer  edge  of  Scalenus  Anticus  and  lower  border  of  First  Rib) — conUnucd. 


No. 


2.J7 


258 


261 
262 


Date  of 
operation. 


(H     tj     fJ 

O  P  <u 

age 

o  o  ■* 

W 


Oct.  22, 
1806. 


Aug.  2, 
183S. 


1869-70. 


186.5. 


April  11, 
186S. 


Sept.  2tl, 
1871. 

Feb.  22, 
1873. 


1S68. 


Vi,  ,S3. 


Oc- 
curred. 


Sth  day. 


Next 
day. 


19 


Condition.    Recovery. 


CauKe  of  death, 
date  after  op. 


Recovered 


Recovered 


Recovered 
Recovered. 


Improved. 


Cured. 


(Improv'd.) 


Cured. 


.S3d  day.     Hem. 


57th  day.     Hem. 


11th  day.  Hemor- 
rhage and  exhaus- 
tion. 


Exhaustion.    ? 


Oil  acouiit  of  Kiippniation,  the 
Hai-  wan  opcnod  siiid  ISouriceH 
of  hloody  pus  were  discharged. 
This  same  iiaticnt  hiid  liad  hiH 
left  subclavian  tied  for  aneu- 
rism 'i  year;*  jirevious  (see  No. 
146)  by  Dr.  Kurncr.  TltH  irann- 
Vf.rHaliH  colli  on  halh  xidf.s  wan 
lied,  ax  it  wan  derive'/  directly 
from  the  nuhdavia.n.  No  doubt 
this  vcBsel  wa.s  the  posterior 
scapula. — Author.) 

Aug.. 30,  1836,  ])T.  F.  had  tied  the 
right  carotid  in  this  piitient. 
By  Sept.  9,  tumor  had  dimin- 
ished notably  in  size,  and  two 
years  after,  althongli  there  was 
no  tumor  visible,  thf  syinptoms 
pointing  to  it.s  re-development 
internally,  the  snhclavian  was 
tied.  Recovered  ;  symptoms 
mitigated,  but  she  died  of  plfu- 
ritis  on  Nov.  27,  1838,  nearly  3 
months  after  the  last  operation. 
Autopsy  sliowed  iniiominate 
alone  to  he  the  seat  of  the  dis- 
ease, and  the  sac  was  filled  with 
dense  coagnlnm, except  a  chan- 
nel buri'owed  through  its  centre 
about  the  size  of  the  innominate. 


Carotid  tied  simult^ineously. 
Carbolized  catgut  used,  and  not 
seen  after  operation.  Tumor 
treated  by  galvano- puncture 
after  ligature.  Sac  suppurated, 
and  death. 

After  ligature,  tumor  consoli- 
dated and  pressed  upon  nerves 
to  such  an  extent  that  Dr.  H. 
induced  suppuration  and  rup- 
ture of  sac,  which  was  success- 
ful in  every  respect. 

Right  carotid  simultaneously. 
1.5  months  after  ligature,  tumor 
was  reduced  in  size,  and  patieut 
much  improved,  notwithstand- 
ing she  was  of  dissolute  habits, 
having  slept  in  the  streets, 
drunk,  all  night,  put  in  jail, 
etc.  etc.  In  Lancet  for  July  2, 
1870, 1  see  this  patient  died  Dec. 
8,  1869,  from  the  "external 
bursting  of  an  aortic  aneurism." 
Autopsy :  Innominate  healthy  ; 
ancui'ism  of  ascending  aorta. 

Sth  day,  rupture  of  internal  j  ug- 
nlar  vein,  which  was  tied  im- 
mediately. No  autopsy.  Carot- 
id was  tied  simultaneously. 

Tumor  at  first  decreased,  but 
afterward  became  larger.  Ca- 
rotid was  tied  simultaneously. 

12  weeks  after  fracture,  resec- 
tion. For  two  mouths  after  this 
last  opei'atiou,  hemorrhage  was 
frequent,  and  occurred  the  day 
after  ligature,  but  was  arrested 
by  compress. 

Axillary  artery  tied  first,  but 
hemorrhage  occurring,  the  sub- 
claviau  was  secured. 


216 


PRIZE    ESSAY. 


Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  (between 


No. 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


O  -^ 

oS  o 

P  s 


265 


266 
267 

268 

269 


270 


275 
276 


277 
278 


279 


Marc,  Dupuy, 
1865. 


Mott,  A.  B., 
1876. 


Gaz.  des  Hop.,  ]870, 
p.  637. 


Orally  to  author. 


Mott,  Valentine, 
do. 

do. 


Operator's  notes, 

kindness  of  Dr.  A.  B. 

Mott. 

do. 


Little,  Jas.  L., 
New  York,1876. 

Panas,  ]S75. 


Sosin. 


Sands,  Prof. 

H.  B.,  1S6.3. 

do.  1868. 


Stocks,  J.  W., 

1 872-3. 
Terrier,  P.,  & 
Le  Fort,  1874. 


"Weir,  R.  F., 
1876. 


Orally  from  Dr. 
Robert  F.  Weir. 

Gaz.  Hebdom.,  Feb. 
11,  1876,  p.  91. 


do. 

Krie2:'s  Chir.  Erfahr. 

Med.'^Surg.  Hist.  Reb. 

vol.  ii.  p.  411. 

do. 

Notes  to  author. 

do. 


Am.  Jr.  Med.  Sci., 

Oct.  1873. 

Gaz.  Hebdom.,  Oct. 

15,  1875,  p.  668. 


Note  to  author. 


L. 


Sol- 
dier 


Axillary  aneu- 
rism (stab  w'd). 


Innominate  aneu- 
rism. 


Axillary  aneur. 
(noted  "  true"). 

Subclav.  axillary 
aneurism  (fall  of 
cask   on   shoul- 
der). 

Encepbaloid  of 
humerus  (ampu- 
tation at   shoul 
der) . 

Aneurism  of  sub- 
clavian. 


Innominate  or 
aortic  aneurism. 

Hem.   (laceration 
by  fall). 


W'nd  of  axillary 
(reduction  of 
shoulder). 

Hemorrhage,  shot 
wound  axilla. 

Aneurism,  axilla- 
ry, shot  wound. 

Hem.,  shot  wound 
left  shoulder. 

Aneurism  at  ster- 
no-clavic.   artio. 
(supposed  in- 
nominate). 


Aneurism  (suici- 
dal pistol  shot 
wound). 


R.    Innominate  aneu- 
rism. 


3  w'ks. 


13  days. 


17  days, 

41  mos. 
4  days. 


3d  divi- 
sion. 


do. 


do. 


do. 
(Close 
to  sca- 
lenus.) 

do. 


do. 


do. 

3d  divi- 
sion. 

do. 

do. 

do. 
do. 
do. 


do. 

do. 


Imme- 
diate 
and 
profuse. 


1.  2,  7, 
12,  13 


July  14. 


Feb.  15, 

1S74. 


Imme- 
diate. 


do. 


INNOMINATE    AND    SUBCIiAVIAN    AKTERIES.  217 

outer  edge  of  Scalenus  Anlicus  and  lower  border  of  First  Rib) — continued. 


Pato  of 
oporatiou. 


S  3  o 


RocoYory. 


Condition. 


Cause  of  death, 
date  after  op. 


KEMARKS. 


July  1, 


1870. 


Jan.  9, 
1S3.3. 


Sept.  1S55. 


Aug.  1,3, 
1875. 


Lig.  17th 
day. 


July  IS, 
186:3. 

July  16, 
1S6S. 


March  3, 
lS7i. 


None. 


5th  day. 


.5th,  9th 
day. 

12,13,14 


6th  day. 


11th 
day, 
from 
sac. 


Rocovei'od. 


Recovered. 
Recovered 

Recovered. 

Recovered. 


Recovered. 


Recovered. 


Recovered. 


Recovered, 


Cured. 


Cured. 
Cured. 


Marked  im- 
provement. 


Cured   (loss 
of  arm) 


Died  2  months.    ? 


9th  day.     Hem. 


14th  day.     Hem. 

19th  day.     Exhai 
tion. 


The  common  carotid  was  tied 
one  yar  i)rovloiiK.  Pati'-nt  r^'- 
covorod.  (1  examined  tliiH  pa- 
tient one  year  after  tlie  ligature 
of  the  Hiibclavian.  A  small 
hard  tumor,  about  the  size  of  a 
nutmeg,  could  lie  felt  to  rise 
with  tlie  cardiac  systole  ;  no 
thrill.  I  consider  the  cure  as 
complete  as  can  he  expected. 
The  patient  was  well  in  every 
respect.) 


Tumor  situated  helow  and  under 
{i.  e.  behind)  clavicle. 


Pulsation  in  tumor  ceased  after 
ligature  to  suhclav.,  but  recom- 
menced in  a  few  minutes.  An- 
other vessel  was  seen  to  pulsate 
along.side  of  subclavian,  which 
was  tied,  and  then  pulsation 
ceased  and  did  not  return. 
{Note  by  aiithor.  — This  last 
vessel  was.  no  doubt,  the  pos- 
terior scapular,  mentioned  in 
the  surgical  anatomy,  which 
see.) 

Carotid  was  tied  simultaneously. 
This  case  will  very  likely  re- 
sult in  a  cure. 

Wound  treated  with  wash  of 
alcohol  and  carbolic  acid.  No 
pulse  was  found  in  radial  3 
months  after  operation. 


12th  day.     Pneumo- 
nia.   I?) 


11th  day.     Hem. 


Eight  carotid  tied  same  time. 
Died  13  mouths  after  operation; 
aneurism  was  from  aorta  and 
extended  in  front  of  the  innom- 
inate. Hemorrhage  was  from 
cax-otid. 

Solidification  of  one  lung. 

Ball  lodged  in  axilla ;  hemor- 
rhage ceased  spontaneously  : 
hem.  6th  day  after  operation; 
gangrene  supervened,  and  arm 
was  amputated  in  lower  3d  of 
liumerus,  on  May  29th. 

Carotid  was  tied  simultaneously; 
rupture  of  aneurism  on  llth 
day  into  trachea:  upper  part  of 
sac  was  filled  with  coagulum. 


218  PRIZE    ESSAY. 

Ligature  of  the  Subclavian  Artery  in  its  Third  Surgical  Division  {between 


Name  of 
operator. 


Source  of 
information. 


Cause  of 
operation. 


pa 


283 
28i 


2So 
2S6 


Wickham 
1829. 


Heath,  G.  Y. 
1876. 


Speir,  S.  Fleet, 
Brooklyn,  1874. 


Norris  Contrib. 


Lancet,  1877,  p.  384. 


Note  from  Dr.  S.  to 
author;  New  York 
Archives  of  Clinical 
Surgery,  Sept.  1876, 
p.  96. 


Maunder,  1867 
(London  Hos- 
pital). 
Harwell,  Rich- 
ard. 


Toland,  1874. 


Stimson,D.  M,. 
1872. 


T.  Holmes  in  Lancet, 
Sept.  1867,  p.  37. 

Lancet,  Nov.  17,  1877; 
Am.  Jr.  Med.  Soi., 
Jan.  1878,  p.  275. 


Van  Buren  in   Traas. 

International   Med. 

Congress,  1876,  p.  ooS. 

Presby.  Hosp.  Report, 

N.  Y. 


Innominate  aneu- 
rism. 


.Axillary  aneu- 
rism (idiopathic). 


Aortic  aneurism 
(supposed  in- 
nominate). 


3d  divi- 
sion. 


Innominate  aneu- 
rism. 

Aneurism  aorta, 
innominate,  ca- 
rotid, and  sub- 
clavian. 


Subclavian   aneu- 
rism. 


do. 
do. 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES.  219 

outer  edge  of  Scalenus  Anticus  and  lower  border  of  First  Rib) — continued. 


No. 


Dato  of 
operation 


4> 

^""^    ^ 
t!   *-    t^ 

o  g  £ 

0^  O  cd 

a 

-a 

Recovery.     Condition. 


Cause  of  death, 
date  after  op. 


280         Deo.  .'!, 
1S2!). 


Nov.  28, 
187G. 


284 


Aug.  6, 
1874. 


None. 


2()-27-2.s 
30-31-32 


Aug.  14, 
1877. 


1874. 
1S72. 


15 
rem'd 


llccovored. 


Recovered. 


Recovered. 
Recovered. 


Cured. 


Much  ina- 
proved. 


(?) 
Cured. 


JJiod  aliout  3  iuoh. 


i2d     day.       Hemor- 
rhage; dyspnoea. 


Died  after  3d  day. 


Carotid  waH  tied  Sept.  20,182:/. 


No  bad  Kymptoms  followed.  In 
Marcli  previou.s  iiaticnt  first  felt 
piiiu  in  sliouldor  ;  in  .June,  flrnt 
appearance  of  tumor;  carbol- 
izcd  catgut  ligature  used. 

2  days  before  ligature  of  suhclu- 
vinn,  tlie  right  carotid  had 
been  obliterated  by  means  of 
Dr.  Speir'a  "  conntrtctor."  The 
carotid  wound  healed  by  firHt 
intention  ;  the  subclavian  went 
on  to  suppuration ;  2d  day, 
tumor  decreased  one-half  in 
size  ;  4th  day,  neuralgia  ;  7th, 
tumor  increasing  and  looks  red; 
18th  day,  inflammation  increas- 
ing, difficulty  of  deglutition  ; 
23d,  intense  pain  through  aneu- 
rism ;  2.5th,  swelling  spreading 
to  right  of  sternum,  with  rnarlf- 
ed  "bruit;"  26th,  hemorrhage 
from  tumor;  27th,  do.  and  pul- 
sation noticed  first  time  in  ra- 
dial ;  2Sth,  .30th,  31st,  and  32d 
days,  hemorrhage  from  sac  ; 
death.  Autopsy:  Displacement 
of  riirht  clavicle,  erosion  of 
manubrinm  ;  liver  waxy  ;  left 
kidney  do.  ;  aneurism  from 
transverse  portion  of  arch  : 
neither  innominate  nor  carotid 
involved  ;  carotid  closed  by  co- 
agnla,  on  both  sides  of  constric- 
tion ;  internal  coat  divided 
and  tii.rned  in;  subclavian  tied 
on  both  sides  of  the  ligature  ; 
thrombus  in  right  subclavian 
vein  ;  sac  full  of  clot.  {Noteby^ 
author. — The  "  constrictor"  of 
Dr.  Speir  seems  to  bid  fair  to 
prove  a  successful  innovation 
in  surgery,  having  been  applied 
to  all  the  large  arteries  with 
success,  by  the  inventor.) 

Carotid  tied  simultaneously. 


Carotid  tied  same  time;  subcla- 
vian in  3d  division  ;  3  months 
after  operation,  patient  was 
considered  out  of  danger,  and 
aneurism  consolidated.  Died  3 
months  after  operation.  See  foot 
of  page  100. 

2  ligatures — Distal.  This  case 
is  not  considered  in  the  sum- 
mary. 

Removed  scapula  and  part  of 
clavicle  for  disease  after  ampu- 
tation at  shoulder.  This  case 
is  not  considered  in  the  sum- 
mary. 


I 


SUMMARY  OF  THE  SURGICAL  HISTORY 


INNOMINATE  AND  SUBCLAVIAN  ARTERIES. 


SUMMARY  OF  THE  CASES  OF  LIGATURE  OF  THE  ARTERIA  INNOMINATA. 

I  HAVE  accepted  as  reliable  16  cases  of  ligature  of  this  vessel. 
The  case  of  Peixoto  was  not  a  ligature  proper,  as  the  thread  was 
only  passed  around  the  artery  and  was  not  tightened.  I  have  no 
reason  to  doubt  the  two  cases  of  Bujalski  reported  verbally  to  Vel- 
peau,  but,  as  I  have  been  unable  to  find  anything  definite  concerning 
them  in  the  literature  of  this  subject,  they  are  noted  and  not  included 
in  the  table.  Porter's  was  a  case  of  acupressure  of  this  vessel. 
Of  the  16  cases  all  were  males.  All  died  except  one,  and  he  re- 
covered, temporarily  cured  of  the  aneurism,  which  returned  and 
caused  death  ten  years  later  (see  Table).  The  ages  given  are  57, 
36,  52,  31,  30,  52,  46,  27,  40,  and  32. 

Of  the  causes  necessitating  the  operation  there  were  — 

Aneurism  of  subclavian — 

Traumatic       . 6 

Idiopathic 3 

Cbaracter  of  aneurism  not  stated o 

Hemorrhage'  of  the  ligature  of  subclavian 1 

Cause  of  operation  not  given         ........  1 

Total      .        .        . 16 

Point  of  Ligature. — Location  indicated  in  only  3  instances.  Once 
"  near  the  aorta."  Once  only  h  inch  below  the  bifurcation  of  the 
innominate.     Once  1  inch  from  the  aorta. 

'  The  case  of  Hutin. 

(221) 


222  PRIZE    ESSAY. 

Hemorrhage  after  Operation. 

Hemorrhage  in  12  cases — 

.  On  cardiac  side  of  ligature  in 3 

On  distal  side  of  ligature  in 5 

Source  not  stated 3 

Into  lungs  (A.  B.  Mott),  rupture  of  sac         .         .         .  1 — 12 
No  hemorrhage  in  3  cases — 

Death  8th  day 1 

"       2d     " .1 

"       (date  not  given) 1 —  3 

15 

Not  definitely  stated  (probably  none)  ;  death  11  hours        .         .     1 

Ligatures  came  away  in  only  4  cases,  respectively  on  the  20th,  17th, 
14th,  14th  days. 

Recovery^  1  case ;  condition  temporarily  cured,  with  slight  and 
probably  temporary  debility  of  right  upper  extremity. 

Causes  of  Death. 

Hemorrhage  alone  after  operation 10 

"         with  pericarditis 1 

Exhaustion  (with  probably  pysemia) 1 

"           (     "           "              "      urasmia) 1 

"            from  loss  of  blood  before  operation           ....  1 

Pyaemia  (alone)            1 

15 

Complications  loith  Ligature. 

Ligature  of  innominate  and  carotid  simultaneously         .  1     A,  B.  Mott. 
Ligature  of  innominate  and  carotid  simultaneously,  and 

vertebral  on  54th  day 1     Smyth. 

Ligature  of  subclavian  (3d  division),  and  innominate  9 

days  later 1     Hutin. 

Ligature  of  innominate  alone 13 

Total 16 

In  the  cases  of  Lizars  and  Valentine  Mott,  an  anomalous  branch 
(probably  the  inferior  thyroid)  was  from  the  innominate  near  the 
ligature.  In  5  of  34  consecutive  cases  examined  as  to  this  feature, 
I  found  this  anomaly  ;  3  of  these  5  were  branches  to  the  thyroid 
body  (the  thyroid  branch  from  the  axis  being  wanting  in  2)  and  two 
were  pericardiac  branches. 

In  the  cases  of  Lizars  and  Mott,  the  hemorrhage  was  from  the 
seat  of  ligature.  (I  do  not  doubt  that  these  abnormal  branches 
were  partial  causes  of  the  non-closure  of  the  innominate.) 


INNOMINATK    AND    SUBCLAVIAN    ARTERIES.  223 

Dales  of  Dealh  after  Operation. 

Days.  26,  67,  8,  5,  18,  22,  17,  84,  23,  6,  9,  2,  2^,  ^;  not  given  1. 
Total,  15. 

Condition  of  Vessel  as  shown  hy  Autopsy. 

V.  Mott.  Innominate  not  occluded  on  cardiac  side  of  ligature.  Portion  beyond 
ligature  had  disappeared  by  sloughing,  but  the  ends  of  carotid  and  subcla- 
vian were  open. 

Graefe.     Cardiac  end  of  artery  occluded,  distal  end  open. 

Bland.  Cardiac  end  occluded,  distal  end  open.  Carotid  was  closed  by  clot,  but 
subclavian  was  open. 

Lizars.     Both  ends  open. 

Gore.  Both  ends  of  innominate  open.  The  carotid  Avas  open,  but  subclavian  was 
closed. 

Arendt.     Died  8th  day.     Ligature  still  in  situ. 

Hall.     Died  5th  day.     Ligature  still  in  situ. 

Bickersteth.  Died  6th  day.  Ligature  still  in  situ.  Clot  in  subclavian,  none  in 
carotid. 

Mott,  A.  B.  Aneurism  burst  into  thorax.  Ligature  separated  on  20th  day.  No 
hemorrhage  at  seat  of  ligature. 

Conclusions. 

To  arrive  at  a  just  conclusion  as  to  the  propriety  of  cleligating 
the  innominate  artery,  it  will  be  instructive  and  necessary  to  com- 
pare with  this  operation  other  and  more  conservative  methods  of 
treatment. 

Of  the  16  cases  given  in  the  history,  14  were  for  relief  of  suh- 
clavian  aneurism.  In  1  the  cause  of  the  operation  is  not  given.  In 
1  other  (Hutin's)  the  cause  of  operation  was  hemorrhage. 

In  this  last  case,  a  punctured  wound  of  the  thoracic  branch  of  the 
axillary  artery  was  the  cause  of  ligature  of  the  sulclavian,  and, 
hemorrhage  again  occurring,  of  the  innominate. 

It  seems  that  to  have  enlarged  the  original  wound  and  secured 
the  bleeding  vessel  should  have  been  the  first  step,  instead  of  liga- 
ture of  the  sxilclavian.  And  after  hemorrhage  occurred  again  (as 
suggested  by  Dr.  Otis  in  the  Medical  and  Surgical  History  of  the 
Rebellion),  amputation  at  the  shoulder  would  have  been  safer  than 
ligature  of  the  innominate. 

In  14  operations  for  subclavian  aneurism  we  have  18  immediately 
fatal,  and  one  "temporarily  cured,"  which  proved  fatal,  from  the 
original  aneurism,  which  reformed  in  the  reversed  collateral  circula- 
tion^ about  ten  years  later. 


224  prize  essay. 

synopsis  of  22  cases  of  subclavian  aneurism  in  which   "  no 
treatment"  was  undertaken. 

18  deaths  ;  4  spontaneous  cures.     (After  PolandO 

18  fatal  cases.     Dates  of  death  after  tumor  was  noticed  (and  when 
surgical  interference  might  have  been  undertaken). 
1  case.     Aneurism  had  existed  for  "  some  time."     Died  12  weeks  after   admission 

to  hospital. 
1  case.     Not  known  how  long  aneurism  had  existed. 
1  case.     Lived  "  some  months."      Died  of  exhaustion  and  suppuration  caused  bj 

pressure  of  sac. 
1  case.     Died  of  rupture  of  sac  24  years  after  recognition  of  aneurism.- 
1  case.     Died  from  asphyxia  caused  by  pressure  of  sac,  8  years. 
1  case.     Died  from  external  rupture  of  sac  2  years  and  8  months  after  recognition 

of  aneurism. 
1  case.     Died  from  exhaustion  from  pressure  of  sac,  2  years  after  recognition. 
1  case.     Died  from  dyspnoea  from  pressure  of  sac,  2  years  after  recognition. 
1  case.     Died  from  dyspnoea  and  exhaustion  from  pressure  of  sac  1^^  year    after 

recognition. 
1  case.     Died  from  rupture  of  sac  into  lungs  Ig^  year  after  recognition. 
1  case.     Died  from  rupture  of  sac  into  lungs  81^  months  after  recognition. 
1  case.     Died  from  rupture  of  sac  into  tissues,  becoming  diffused,  and  causing  death 

by  pressure  5^  months  after  recognition. 
1  case.     Died  from  rupture  of  sac,  death  by  pressure  5  months  after  recognition. 
1  case.     Died  suddenly  (probably  from  cerebral  clot)  1^  year  after  recognition. 

1  case.     Died  suddenly,  cause  not  stated,  not  rupture  of  sac. 

2  cases.   Died  from  rupture  of  popliteal  aneurisms. 

1  case.     Died  from  typhoid  pneumonia  3  years  after  recognition. 

Of  the  4  cures,  3  remained  well ;  1  died  about  4  years  later  from 
rupture  of  an  aortic  aneurism.  Of  these  18  fatal  cases  in  which 
no  treatment  was  undertaken,  3  died  of  other  disease  than  the 
aneurism. 

Of  the  13  cases  in  which  the  duration  ot  life  is  noted  after  the 
recognition  of  the  aneurism,  the  sum  total  is  47  years  and  9  months 

The  sum  of  life  in  the  13  cases  after  deligation  of  the  innominate 
is  about  8  months,  a  difference  in  favor  of  non-interference  (in  an 
equal  number  of  cases)  of  about  47  years  of  life. 

An  examination  of  the  cases  on  the  next  page  will  show  that 
judicious  treatment  without  ligature  is  a  more  successful  method 
than  either  this  latter  or  perfect  non-interference. 


INNOMINATE    AND    SUBCLAVIAN    AltTEI4IK3.  225 

SYNOPSIS    OF    14   CASES   TREATED   BY    VALSALVA'S    METHOD. 
(More  or  less  modified.) 

1  case.  M. ;  R.  Subclavian  aneurism.  Size,  hen's  egg.  Venesection  ;  cold  and 
lead  lotion  locally.  Recovered.  Two  and  a  half  years  later  was  work- 
ing as  a  carter  in  the  city. 

1  case.  M. ;  R.  Subclavian.  Immense  size.  Venesection.  Cold  and  astringents 
locally.  Tumor  reduced  in  size  and  firmer;  lost  sight  of  while  in  pro- 
cess of  cure. 

lease.  M. ;  R.  Subclavian  (syphilitic)r  Valsalva's  method  and  antisyphilitics. 
Cure  complete. 

lease.  M.;  R. ;  age  45.  Subclavian  (syphilitic).  Valsalva's  method  and  anti- 
syphilitics.    Cured  and  seen  well  6  years  later. 

1  case.  M. ;  age  42.  Subclavian.  Venesection.  Digitalis.  Rest.  Marked  im- 
provement, so  that  patient  left  hospital  and  was  lost  sight  of. 

1  case.  M. ;  age  50.  Subclavian.  Was  treated  for  an  intercurrent  attack  of  rheu- 
matism by  rest,  strict  diet,  and  antiphlogistics.     Cured. 

1  case.  M. ;  age  39.  Subclavio-axillary  (Pancoast's  case).  Valsalva's  method  had 
been  tried  and  considered  a  failure.  Operation  determined  on.  Carried 
into  operating  room.  Patient  fell  into  collapse  and  operation  was  post- 
poned. Recovered  cured.  (It  is  stated  that  a  large  dose  of  aconite  had 
been  given  by  mistake  just  before  the  operation  was  to  have  taken 
place.) 

1  case.  M. ;  age  37.  Subclavian.  Venesection.  Valsalva's  method  and  careful 
and  persistent  direct  compression  for  1^  year.     Cured. 

1  case.  M. ;  age  51.    Subclavio-axillary  (by  Pelletan).    Valsalva's  method.   Cured. 

5  cases  treated  by  this  method  (in  part)  were  fatal.  Venesection  was  not  practised 
except  in  one  case.  Only  local  and  constitutional  treatment.  All  died 
within  12  months  of  the  recorded  recognition  of  the  disease ;  1  from 
ulceration  into  trachea,  haemoptysis,  and  exhaustion;  2  from  external 
bursting  of  sac ;  2  from  exhaustion  and  coma  (with  pressure  on  the 
trachea  in  one  case). 

Summary. — 14  cases.  Cured  7  ;  improved,  and  in  process  of  cure 
when  lost  sight  of,  2  ;  died  5.  No  venesection  in  4  of  5  fatal  cases. 
1  successful  case  modified  by  direct  pressure. 

SYNOPSIS   OF    6    CASES   TREATED    BY    DIRECT   PRESSURE    UPON 

THE   SAC   (modifications   GIVEN). 

(All  subclavian  aneurism.) 

1  case.  M. ;  46  years  ;  R.  Leather  "  cup"  moulded  over  tumor  and  held  in  place 
by  figure-of-8  straps  around  shoulders  and  axilla.  Cured  in  14  months. 
Did  light  work  during  treatment,  and  had  no  other  medication. 

lease.  M.;  39  years;  L.  Enormous  size.  Treated  by  cold  and  pressure  "in 
turns."  Small  cannon-ball  suspended  so  as  to  press  comfortably.  Dis- 
charged relieved.  Some  months  later  violent  inflammation  (from  fall), 
suppuration,  rupture  of  sac,  discharged  two  quarts  of  pus  and  blood. 
Cured.     Debility  of  arm  probably  permanent. 

15 


226  PRIZE    ESSAY. 

1  case.  M. ;  41  years.  (13  months'  dui'ation.)  Kept  in  bed,  on  back,  ice  locally, 
restricted  diet.  3d  day  air  cushion  for  12  hours  with  intermissions 
amounting  to  3  hours.  Every  half-hour  interval  of  ice.  Treatment  for 
7  days.     Tumor  began  to  subside  and  was  cured  in  12  months. 

1  case.  (T.  Holmes.)  [Lancet,  Feb.  12,  1876,  p.  237.)  Subclavian.  Treated  by 
direct  pressure  from  rubber  ball.     Cured. 

1  case.     (Dupuytren.)     Direct  pressure.     Eesulted  fatally. 

1  case.  (Porter.)  Exposed  axillary  and  passed  needle  under  it.  35  days  later 
exposed  innominate  and  passed  the  "  acupressure  needle"  under  it. 
Died  from  hemorrhage  from  innominate  on  10th  day. 

(In  1  case  given  in  preceding  table,  direct  pressure  was  practised 
with  Valsalva's  method.) 

Summary. — 5  cases  of  "direct  pressure"  (without  operative  pro- 
cedures).    Cured  4  ;  died  1. 


SYNOPSIS  OF  CASES    OF    MASSAGE    OR  KNEADING   IN    THE   TREATMENT 
OF   SUBCLAVIAN   ANEURISM. 

Of  this  method  there  are  6  cases. 
3  cured  ;  viz.,  by  Fergusson,  Little,  and  Porter. 
3  died ;  viz.,  by  Fergusson,  Hilton,  and  Morgan. 

(See  Guy's  Hospital  Reports,  vol.  xvi.  p.  42  et  seq.) 

In  addition,  Mr.  Bryant,  in  his  "Practice  of  Surgery,"  p.  190, 
gives  a  case  by  Dutoit,  of  Berne,  in  which  a  subclavian  aneurism 
was  cured  by  injection  of  ergotin  around  the  sac  under  the  skin, 
and  digital  compression. 

Poland  cured  one  case  by  digital  pressure  on  cardiac  side.  A 
third  case  was  tried  for  46  hours  and  abandoned  on  account  of  pain 
from  pressure.  The  patient  died  from  exhaustion.  Paget  tried 
mechanical  pressure  in  a  fourth  case,  but  abandoned  it  as  a  hopeless 
undertaking,  A  fifth  case  by  Yerneuil  was  improved,  but  lost 
sight  of  before  a  cure  was  effected. 

Conclusions. 

1.  That  the  circumstances  justifying  ligature  of  the  arteria  inno- 
minata,  for  the  cure  of  subclavian  aneurism,  will  occur  so  rarely 
that  practically  the  operation  should  be  abolished. 

2.  That  nature,  unaided,  is  more  successful  than  surgery  which 
ligatures  the  innominate. 

3.  That  judicious  venesection,  prersistent  and  perfect  rest  in  bed, 
restricted  diet,  careful  medication,  combined  with  a  determination, 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES.  227 

on  the  part  of  both  patient  and  surgeon,  to  succeed,  is  safer  and 
more  certain  of  success  than  either  nature  or  the  ligature. 

4.  That  direct  pressure  by  means  of  any  substance  that  will  press 
equally  upon  the  entire  surface  of  the  tumor  (Holmes's  elastic  ball 
seems  best  adapted),  applied  gradually,  in  order  to  accustom  the 
patient  and  the  tumor  to  its  presence,  in  connection  with  the  last 
method  above  mentioned,  is  surest  of  success  as  compared  with  all 
known  methods  of  treatment. 

5.  That,  should  all  these  means  fail  after  a  persistent  trial,  should 
the  sac  by  ulceration  open  and  threaten  instantaneous  death,  or 
should  the  surgeon  from  the  appearances  judge  that  this  accident 
was  on  the  eve  of  occurring,  then  I  should  deem  ligature  of  the 
innominate  artery  justifiable  and  imperative.  As  insisted  upon  in 
the  "operative  surgery"  in  connection  with  this  vessel  (which  see), 
the  artery  should  be  twisted  after  being  tied,  the  carotid  treated  in 
the  same  manner,  and  the  subclavian  tied  near  the  innominate.  It 
is  most  probable  that  this  last  vessel  will  be  so  involved  in  the  disease 
that  torsion  would  scarcely  be  safe.  In  all  cases  the  vertebral,  the 
thyroid  axis  (or  its  branches),  the  internal  mammary,  the  intercostal, 
and  the  posterior  scapular  should  be  tied  or  twisted. 

6.  That  "kneading,  or  massage,"  has  an  element  of  danger  in  the 
suddenness  of  its  action,  and  is  inferior  to  the  above  method. 

7.  That  pressure  on  the  cardiac  side  is  scarcely  practicable;  while 
pressure  on  the  distal  side  is  dangerous  and  useless  as  compared  with 
other  methods. 

8.  That  the  introduction  of  wire,  horsehair,  acupressure,  galvano- 
puncture,  and  injections  into  the  cavity  of  the  sac  are  not  to  be 
practised. 

9.  That  in  wounds  of  the  innominate  it  should  be  tied  and  twisted 
(as  heretofore  given),  and  the  carotid  and  subclavian  treated  as 
before. 

[In  case  the  carotid  were  wounded  within  half  an  inch  of  the  in- 
nominate, or  the  subclavian  within  the  same  distance,  I  would  consider 
it  safer  to  practise  ligature  of  both  carotid  and  subclavian,  and  then 
torsion  of  both  "stumps"  with  the  innominate — the  distal  ends  of 
these  two  vessels  to  be  treated  as  above.  Especially  would  I  insist 
upon  this  in  wounds  of  the  subclavian,  since  ligature  of  this  artery  in 
its  first  surgical  division  has  invariably  proved  fatal.  (See  19  cases 
in  history.)] 


228 


PRIZE    ESSAY, 


GENERAL  SUMMARY  OF  CASES  OF  LIGATURE  OF  THE  SUBCLAVIAN 

ARTERY. 

This  collection  of  cases  includes  283  instances  of  ligature  of  the 
subclavian  artery  (all  in  the  third  surgical  division,  excepting  32). 

The  sex  is  given  in  262  cases;  of  this  number  240  were  males 
and  07ily  22  females;  an  unmistakable  indication  that  exposure  and 
violence  are  causes  of  the  lesions  requiring  so  grave  an  operation. 

As  to  the  side  of  body,  mention  is  made  in  222  cases  ;  of  which 
132  are  on  the  right,  and  90  on  the  left  side. 

The  ages  of  the  patients  were  as  follows  (as  far  as  noted): — 


17  years  of  age 

1 

43  years  of  age 

3 

18   "   "  " 

3 

44   "   "  " 

1 

19   "   "  " 

4 

45   "   "  " 

2 

20   "   "  " 

6 

46   «  u     » 

1 

21   "   »  " 

13 

47   "   "  " 

3 

22   »   "  "   ■  . 

8 

48   "  "     " 

3 

23   "   "  " 

4 

49   «   "  " 

2 

24   "   "  " 

2 

50   "   "  " 

8 

25   "   "  " 

5 

51   "   "  " 

3 

26   "   "  " 

2 

53   "   "  " 

.   1 

27   "   "  " 

4 

54  u      u  u 

4 

28   "   "  " 

7 

55   "   "  " 

.   3 

29   "   "  " 

3 

56   "   "  " 

.   1 

30   "   "  " 

11 

57   "   "  " 

.   1 

31   "   "  " 

5 

59   "   "  " 

.   1 

32   "   "  " 

6 

60   "   "  " 

.   3 

33   "   "  " 

8 

61   "   "  " 

.   2 

34  "   "  "    .    •  -  . 

5 

63   "   "  " 

2 

35   "   "  " 

11 

65   "   "  " 

1 

36   »   "  " 

9 

68   "   "  " 

1 

37   "   "  " 

6 

73   "   "  " 

1 

38   "   "  " 

4 

Noted  as  old  . 

1 

39   "   "  " 

4 

"  child 

.   1 

40   "   "  " 

13 

"   "  young 

2 

41   "   "  " 

.   3 

"   "  middle-aged 

15 

42   "   "  " 

.   3 

A  resume  by  decades  shows  that  accidents  leading  to  ligature  of 

the  subclavian  are  more  apt  to  occur  in  the  "active  periods"  of  life. 

Under  20  years  there  were  only 9  cases. 

From  20  to  30  years  there  were 48     " 

"      30    "  40    "        "        " 69    " 

"      40    "  50     "         "         " 34    " 

"      50    "  60     "         "         " 22     " 

"      60    "  73    "        "        " 10     " 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES. 


229 


7  th  day 

1 

9   " 

1 

10   " 

2 

11   " 

6 

12   " 

10 

13   " 

8 

14   " 

3 

15   " 

7 

16   " 

5 

17   " 

7 

18   " 

8 

19   " 

6 

20   " 

4 

21   " 

4 

22d 

day 

23 

11 

24 

If 

26 

a 

27 

" 

29 

li 

31 

a 

32 

" 

34 

il 

36 

« 

43 

« 

47 

i( 

85 

<f 

96 

(( 

Hemnrrliage. 

Of  283  cases,  hemorrhage  is  given  as  occurring  after  the  opera- 
tion in  93.  There  is  stated  "no  hemorrhage"  in  37  cases.  In  the 
remainder  this  accident  either  did  not  occur,  or  it  is  not  noted  in 
the  account  if  it  did.  It  is  evident  that  no  exact  conclusion  can  be 
reached  as  to  the  proportion  of  cases  in  which  hemorrhage  may 
occur. 

The  source  of  the  hemorrhage  was  as  follows  in  the  few  cases  in 
which  it  is  specified: — 

At  seat  of  the  ligature  (side  not  stated)  .....  10  cases. 

"  "  "        (from  distal  end  of  artery)  ...  13 

"  "  "        (from  central  end  of  artery)         .         .  6 

"  "  "        (both  central  and  distal  end  of  artery)  3 

At  seat  of  lesion  beyond  ligature 31 

From  the  carotid  artery 2 

From  the  internal  jugular  vein         ......  1 

From  rupture  of  sac  on  cardiac  side  of  ligature  (Brasdor- 

Wardrop) 5     " 

Total 71 

Ligature  came  away  on — 

3 
3 
3 
1 

1 
1 
1 
1 
1 
1 
I 
1 
1 
1 


Result. 

Of  283  cases  of  ligature  of  the  subclavian  in  its  three  surgical  di- 
visions, 162,  or  57  per  cent.,  were  fatal. 

The  condition  of  the  121  recoveries  will  be  found  under  the 
special  summaries. 


2S0 


PRIZE     ESSAY. 


Death  occurred  as  follows  : — ■ 


In  a  "  few  miDutes"  in 

1  case. 

In  a  "half-hour"  io 

1     " 

la,"' 6  hoars"  in    . 

2    " 

In  a  "  few  hoars"  in 

1    " 

In  18  hoars  io 

1    " 

In  1  day  in  . 

3    " 

On    2d  day  in 

6     " 

"      3         "           -         . 

6     " 

11 


"     3' 

Si. 

6     ' 

"    10 

u 

3     ' 

i 

"    11 

u 

6     ' 

"    12 

" 

1     ' 

"   13 

" 

4     ' 

u     14 

" 

3     ' 

'•   15 

u 

4     ' 

«   IG 

u 

3    ' 

i 

Causes 

of  death  as  given- 

— 

Hemorrhage  alone  in    , 

47 

a 

and  pleuritis     . 
bronchitis 

1 

1 

it. 

and  py£emia 
and  pneumonia 
and  exhaustiou 

3 

2 
13 

u 

and  dyspnoea     . 
erysipelas,  &  pie 
exhaustion,  and 

raritis 
gan- 

2 

1 

grene     .         . 
"          exhanstioD,  and  diar- 

1 

rhoea 

1 

Phlebitis 

. 

. 

2 

Suffocation 

. 

. 

1 

Shock 

. 

. 

2 

Pleuritis 

. 

2 

"        pneumonia,  emphysenaa . 
"        pericarditis,  pj'semia 

I 
1 

On  18th  d 

ay  in    . 

.     3  cases 

"    19 

.     1      " 

"   20 

.     2      " 

"   21 

.     2      " 

"   22 

.     4     " 

"    25 

.     2      " 

"   27 

.     1      " 

"   29 

.     2      " 

"   30 

.     2      " 

"    31 

.     1      " 

"    32 

•     1      " 

"    33 

.     1      " 

"   35 

.     1      " 

"   36 

.     1      " 

"    37 

.     1      " 

"   46 

.     2      " 

"    57 

.     1      " 

"    60 

.     2      " 

"    62 

.     1      " 

"    65 

.     2      " 

"    90 

.     1      " 

Pneumonia  and  pneumothorax 
Exhaustion  " 

Cerebral  anaemia . 

"       symptoms 
Exhaustion,  pygemia,  gangrene 
Pneumonia  .... 
Pytemia        .... 
Bronchitis    and    pulmonary  con 

gestion 
Inflammation  of  sac,  pleuritis,  per: 

carditis 
Exhaustion  and  pyasmia 
Gangrene     .... 

"  and  pyaemia 

Exhaustion  and  gangrene  . 
Septicaemia  .... 
Exhaustion  .... 
Cause  not  given  in 


1 
1 
1 

1 

3 

2 

28 

18 


SUMMARY  OF  LIGATURE  OF  THE  SUBCLAVIAN  IJS"  ITS   FIRST   SURGICAL 

DIVISION. 

I  have  been  able  to  obtain  positive  results  in  19  cases  of  the  above 
operation.  Death  folloived  in  each  case.  13  were  ligatures  of  the 
subclavian  alone;  6  of  the  subclavian  and  carotid o^  the  right  side. 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES. 


231 


LIGATURE  OF  THE  SUlJGLAVrAN"  ALONE. 
(All  on  riirlit  side  but  one.) 


The  cause  of  the  operation  was — 

Subclavian  aneurism  in      . 
Subclavio-axillary  aneurism  in 
Shot  wound  of  subclavio-axillary  region  in 
Cause  not  jyiven  in     ....         . 


8  cases. 
2     " 
2     " 
1     " 


Total 13 

Hemorrhage  occurred  after  the  operation  in  10  of  tliese  13. 

No  hemorrhage  occurred  in  2  cases  (one  of  these  dying  on  the 
4th  day  ;   the  other  in  half  an  hour  after  operation). 

In  one  case  no  mention  is  made  of  hemorrhage.    Death  on  4th  day. 

The  autopsies  showed  that  in  the  10  cases  in  which  liemorrhage 
occurred  it  was  from  beyond  the  ligature  in  6,  viz.: — 

From  rupture  of  sac  in      ........       1  case. 

"     distal  end  of  artery  at  ligature  in 5     " 

(In  these  5  cases  a  firm  clot  was  found  in  central  end  of  tlie  vessel.) 

From  rupture  of  the  artery  at  seat  of  ligature           .         .         .       2     " 
No  autopsy  made  of  hemorrhage  in 2     " 

Total 10 


Causes  and  dates  of  Death. 


Hemorrhage  alone 


"     and  pneumonia 
"     and  bronchitis 

Pericarditis,  pleuritis,  and 

Exhaustion 

Cause  not  given 


Total     . 
Hemorrhage    had 
(Ay res  and  Bullen). 


occu 


pyaemia 


1 
1 
1 
1 
1 
1 
1 
1 
1 
1 
1 
1 
1 

13 


4th  day 
18th     '• 
24     hours. 
IStli  day. 
36tk 
15th 
lltli 

8th 

22d 
12th 

4th 
half  an  hour. 

4th  day. 


rred    previous    to    operation    in    2    cases 


232  PRIZE    ESSAY. 

LIGATURE  OF  SUBCLAVIAN  IN  ITS   FIRST   DIVISION  AND  THE  COMMON 
CAROTID.      (SIMULTANEOUSLY.) 

Causes  of  Operation. 

Subclavian  aneurism  in 2 

Innominate         "       « \ 

Aortic  (supposed  innominate  aneurism)  in 1 

Bayonet  wound  in  first  intercostal  space  in 1 

Vascular  tumor  of  frontal  region  in 1 

Total 6 

Hemorrhage  occurred  after  ligature  in  4  of  these  6.  Of  the  4 
cases  of  hemorrhage  3  were  from  the  distal  end  of  the  subclavian, 
one  from  the  carotid. 

Dates  and  Causes  of  Death. 

Hemorrhage  alone 1  13th  day. 

1  42d  " 

1  16th  " 

1  10th  " 

Cerebral  ansemia 1  6th  " 

Cause  not  given 1  2d  " 

Total 6 

Operators — Listen,  Eossi,  Parker  (vertebral  tied  same  time),  Ho- 
bart,  Cuveillier,  Kuhl  (subclavian  included  by  accident?). 

Comment  is  scarcely  necessary  upon  the  operation  for  ligature  of 
this  artery  in  its  first  division.     19  operations,  19  deaths. 

The  ligature  of  the  innominate  gives  a  better  result,  16  operations 
and  1  recovery  and  temporary  cure. 

There  can  be  little  doubt  that  the  cause  of  death  to  such  an 
alarming  extent  is  due  to  the  uninterrupted  currents  of  blood  from 
the  smaller  vessels  coming  off  from  the  main  trunk  in  dangerous 
proximity  to  the  point  of  ligature.  In  the  majority  of  cases  the 
vessel  was  closed  by  a  safe  clot  on  the  cardiac  side  of  the  ligature. 
I  am  of  the  opinion  that  the  impaction  of  the  blood  current  has 
no  little  to  do  in  consolidating  this  cardiac  clot,  while  the  current 
which  is  inverse  in  the  smaller  arteries  beyond  the  ligature  retards 
the  formation  of  a  coagulum  by  exerting  a  suction  force  in  the  flow 
of  the  blood  current  toward  the  periphery. 

Conclusions  as  to  the  Propriety  of  Ligature  of  the  Subclavian  Artery 
in  its  1st  Surgical  Division. 
1.  That  for  aneurism  upon  the  cardiac  side  of  the  ligature  (Bras- 
dor-Wardrop)  this   procedure  is  not  justifiable,  since  death    has 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES,  233 

occurred  in  every  instance.     Tlie  vessel  should  bo  tied  in  its  3d 
division  (Wardrop). 

2.  That  for  aneurism  upon  the  distal  side  of  the  ligature,  the 
operation  is  not  safe.  The  same  reasons  given  for  opposing  the 
ligature  of  the  innominate  are  applicable  here;  as  is  the  treatment 
for  the  existing  aneurism.  (See  treatment  of  subclavian  aneurism 
under  summary  of  the  innominate.) 

3.  That  for  injury  to  the  subclavian  in  its  1st  division  requiring 
the  ligature,  it  should  be  secured  on  both  sides  of  the  lesion.  Plvery 
branch  within  three-quarters  of  an  inch  of  each  ligature  should  be 
also  tied.  Should  the  cardiac  ligature  necessarily  be  placed  within 
one -half  inch  or  less  of  the  arteria  innominata^  then  the  carotid  should 
be  tied  with  a  double  ligature,  divided  between  the  two,  the  upper 
portion  twisted,  while  the  innominate  with  its  two  "stumps"  should 
be  twisted  in  the  same  manner.  This  may  at  first  seem  somewhat 
too  "heroic,"  but  since  19  deaths  have  occurred  in  succession,  and 
since  the  autopsies  have  shown  that  hemorrhage  is  not  so  much  to 
be  dreaded  on  the  cardiac  as  on  the  distal  side,  I  am  convinced  that 
all  these  precautions  are  essential. 

SUMMARY   OF   LIGATURE   OF   THE    SUBCLAVIAN   IN   ITS   2d   SURGICAL 

DIVISION. 
(8  cases  upon  the  left ;  5  upon  the  right  side.) 

This  vessel  has  been  tied  behind  the  scalenus  in  18  cases;  died 
9,  or  69  per  cent.;  recovered  and  cured  4.  The  carotid  was  secured 
in  none  of  these  operations. 

The  causes  of  the  ligature  were — 

Axillary  aneurism  in 4 

Subclavio-axillary  aneurism  in 5 

Shot  wound  of  axilla  in 2 

Medullary  fungus  (supposed  aneurism)  in  .         .         .         .         .         .         1 

Punctured  wound  of  axilla 1 

Total 13 

Hemorrhage  followed  the  operation  in  5  instances ;  2  recovered, 
3  died. 

From  seat  of  ligature  (both  ends  of  vessel  open)        ....        1 

"      wound  well  beyond  ligature 3 

"      a  vein 1 

Of  the  4  recoveries  all  are  reported  as  cured  (one  with  amputation 
at  shoulder-joint  on  account  of  gangrene). 


234  PRIZE    ESSAY. 

Causes  and  Dates  of  Death. 

Hemorrhage  alone 1     14tli  day. 

"  "  ........  1       6  hours. 

'  "  "  .         .         .         .         .         .         .         .  1       4th  day. 

Pneumonia       " 16 

Exhaustion       " 115 

"  pyaemia,  and  gangrene 1     12 

Pyaemia  alone  19 

Cerebral  complications 12^ 

Bronchitis  and  pulmonary  congestion  .         .         .         .19 

(Hemorrhage  bad  occurred  previous  to  the  opei'ation  in  5  in- 
stances.) 

In  one  of  the  above  fatal  cases  the  ball  had  wounded  the  lung. 
In  another  the  axillary  had  been  previously  tied,  and  after  ligature 
of  the  subclavian  the  arm  was  amputated  at  the  shoulder.  A  third 
fatal  case  was  attempted  removal  of  a  malignant  fungus. 

The  ligature  of  the  left  subclavian  in  its  second  division  is  prac- 
tically as  safe  as  that  of  the  third  division,  since  the  comparative 
length  of  the  first  division  has  removed  it  further  from  the  great 
trunk. 

The  4  cases  of  recovery,  of  the  13  instances  of  ligature  at  this 
point,  were  all  on  the  left  side. 

Conclusions. 

1.  In  the  left  subclavian^  the  application  of  the  ligature  to  its 
second  division  is  subject  to  the  same  rules  and  is  as  safe  as  that  of 
ligature  in  the  third  surgical  division  (which  see). 

2.  Since  the  average  length  of  the  first  portion  of  the  right  sub- 
clavian is  1.15  inch,  it  would  seem  that  it  should  be  safer  to  apply 
the  ligature  in  the  second  than  in  the  first  part,  yet  in  the  five  in- 
stances in  which  this  operation  has  been  performed  it  lias  proved  as 
invariably  fatal  as  that  in  the  first  division. 

As  in  the  operation  within  the  scalenus,  every  effort  should  be 
made  to  avoid  the  application  of  the  ligature ;  but  when  the  ne- 
cessity still  exists,  the  scalenus  should  be  completely  divided,  and 
all  the  neighboring  branches  tied  on  either  side  of  the  two  ligatures, 
between  which  the  main  trunk  should  be  divided  and  each  end 
twisted  securely,  when  it  is  not  involved  in  the  disease  to  such  an 
extent  as  to  contra-indicate  torsion. 


INNOMINATE    AND    SUBCLAVIAN    AliTERIES.  235 

SUMMARY  OF  LIGATURES  OF  THE    SUIKJLAVIAN  AHTKliY  IN    ITS   THII'.I) 

SUKGICAL  DIVISION. 

(Between  th(3  outer  border  of  the  scalenus  anticus  muscle  and  the  lower 

border  of  first  rib.) 

I  have  found  in  the  literature  of  this  subject  up  to  date  (November, 
1877),  and  have  accepted  as  belonging  properly  to  the  third  divi.sion 
of  the  subclavian  artery,  251  cases  of  ligature.  I  have  rejected 
more  than  100  cases  which  have  been  considered  and  reported  by 
some  writers  as  cases  of  subclavian  ligature,  because,  in  a  large 
number  of  these,  the  description  of  the  method  of  operating  and 
the  point  of  ligature  indicated  clearly  that  the  axillary  was  tied  and 
not  the  subclavian.  In  other  cases  no  result  of  the  operation  was 
given,  which  rendered  its  acceptance  useless.  Between  13  and  20 
of  my  cases  were  tied  heloiv  the  clavicle,  but  from  a  detail  of  the  pro- 
cedure and  the  character  of  the  lesion  I  have  taken  these  to  be  true 
cases  of  subclavian  ligature. 

Of  these  251  cases,  ISi  died,  or  53+  per  centum.  Of  the  117 
recoveries,  the  great  majority  were  cured.  (The  condition  of  re- 
covery will  be  given  under  each  special  summary.) 

SPECIAL   SUMMARY. 
(Hemorrhage.) 

Ligature  of  the  Subclavian  in  its  third  portion  on  account  of  Hemor- 
rhage from  Gunshot  Woimcls. 

Under  this  heading  there  are  49  cases,  of  which  onl}'-  8  recovered, 

a  mortality  of  83+  per  cent.     All  were  cases  in  military  practice 

with  probably  only  two  exceptions.     A  synopsis  of  the  date,   and 

cause  of  death,  and  complications  of  the  operation  is  subjoined. 

Fatal  cases.     Ligature  after  gunshot  wounds. 

9  cases  (uncomplicated).    Died  of  hemorrhage  alone  on  5th,  4th,  5th,  2d.  l'2ih, 

21st,  13th,  9th,  9th  days  respectively. 
4  cases  (uncomplicated).     Pytemia  alone.     (Only  one  date  given)  4th  day. 
2  cases  (uncomplicated).     Exhaustion  alone.     On  the  29th  aud  19th  days. 
4  cases  (uncomplicated).     Exhaustion  and  hemorrhages.     16th,  9th  days,  IS 

hours  and  2  hours. 
I  case    (uncomplicated).     Gangrene,  10th  day. 

1  case    (uncomplicated).     Gangrene,  pyaemia,  and  exhaustion,  6th  day. 
1  case    (uncomplicated).     Pyaemia  and  hemorrhage,  (?) 
1  case    (uncomplicated).     Pleuritis,  erysipelas,  aud  hemorrhage.  Sth  day. 
1  case    (uncomplicated).     Hemorrhage    (before    operation),    exhaustion.    31st 

day.  (?) 
1  case    (civil,  uncomplicated).     Hemorrhage,  gangrene,  exhaustion,  3d  day. 
1  case    (uncomplicated).     Pneumothorax,  pneumonia,  2d  day. 
4  cases  (uncomplicated).     (?)     (Only  two  dates  given)  11th  and  4th. 


236  PRIZE    ESSAY. 

2  cases  (with  excision  of  humerus).     Exhaustion,  6th  and  9th  days. 

lease    (with  excision  of  humerus).     (?)     2d  day. 

1  case    (exsection  head  of  humerus).     Hemorrhage,  3d  day. 

1  case    (exsection  head  of  humerus).     Exhaustion,  pneumothorax  next  day. 

2  cases  (amputation  at  shoulder).     Exhaustion,  11th  and  20th  days. 

1  case  (amputation  at  shoulder).     Gangrene  and  exhaustion,  few  hours. 

1  case  (amputation  at  shoulder).     (?)     2d  day. 

1  case  (amputation  upper  third  humerus).     Exhaustion,  same  day. 

1  case  (amputation  upper  third  humerus).     Pyaimia,  22d  day. 

41  Total. 

All  of  these  except  1  were  gunshot  wounds,  treated  on  the  field, 
or  in  military  hospitals.  A  second  case  was  a  civilian  wounded  by 
a  pistol  shot,  but  treated  in  an  army  hospital. 

Of  the  8  recoveries  only  1  was  in  civil  practice. 

1  case  of  shot  wound  of  lung  and  subclavian  artery. 
1  case  of  amputation  at  shoulder  (No.  182). 
1  case  of  amputation,  upper  3d  (No.  IS,')). 
1  case  of  resection  of  humerus  (No.  215). 

1  case  (civil)  small  shot  wound,  axilla  (contraction  of  flexor  muscles  with  fixa- 
tion of  fingers). 

3  cases.    Nothing  of  interest  given. 

8  Total.' 

Lacerated  Wounds  (not  gunshot). 

1  case  caused  by  fractured  humerus.     Died,  pyaemia,  7th  day. 

1  case  caused  by  dislocation  of  humerus  (amputation  at  shoulder).     Died  of 

exhaustion  next  day 
1  case  caused  by  fall.     Recovered,  cured. 
Total  3  cases:  Died  2  ;  recovered,  cured,  1. 

Wound  (character  not  stated). 
Only  1  case.     Recovered  1. 

PiMictured  Wounds. 
Fatal  cases.     Cause  and  date  of  death  : — 

1  case  (scissors  blade).     (Innominate  tied  later,  No.  99.)     Died  of  hemorrhage 

10th  day. 

2  cases.     Hemorrhage,  on  5th  and  11th  days. 
1  case.     Gangrene,  on  8th  day. 

4  Total. 

'  Of  8  recoveries  the  side  is  stated  in  5.  Four  of  these  5  were  on  the  left  side. 
This  would  indicate  that  wounds  of  the  left  side  are  less  dangerous,  which,  from 
the  stand-point  of  surgical  anatomy,  I  am  inclined  to  believe.  The  condition  of 
these  5  (given)  recoveries  is  as  follows  :  Paralysis  of  arm ;  total  disability  of  arm ; 
partial  disability  of  arm  ;  amputation  at  shoulder;  amputation  in  upper  3d  hume- 
rus; in  1  case  respectively.  All  gunshot  wounds  were  in  males;  22  on  right,  21 
on  left  side,  as  far  as  given. 


INNOMINATE    AND    SUBCLAVIAN    AliTERIES, 


237 


Cases  of  recovery  : — 
1  ciise  (tlirust  with  n!(l-hol  j)oker). 
1  caso  (point  of  scytlie  l>la(k>)-     Arnpiit:ition  (No.  lOl). 
7  cases  (nothing  specially  interesting  in  character  of  injury;. 

9  Total. 
Of  punctured  wounds  there  are  13  cases,  with  9  cures;  4  deaths. 
Ratio  of  mortality  31  per  cent. 

Ligature  of  the  Subclavian  in  its  Bd  Division  on  account  of  Surrjical 

Procedures. 
Synopsis  of  fatal  cases.     Cause  and  date  of  death  : — 

1  case.  "Wound  of  axillary  in  reduction  of  shoulder.     Died  of  exhaustion  and 

gangrene,  6th  day. 

1  case.  After  amputation.     Prostration,  6th  day. 

1  case.  After  amputation.     Prostration,  ? 

1  case.  After  ligature  of  axillary  for  shot  wound,  a  few  minutes. 

1  case.  After  reduction  of  shoulder,  2  months. 

1  case.  After  removal  of  head  of  humerus.     Exhaustion,  25th  day. 

1  case.  After  excision  of  head  of  humerus.  ?  ? 

1  case.  After  opening  abscess  of  axilla.     Pyaemia,  6th  day. 

1  case.  After  dividing  cicatricial  contractions  of  axilla.  ? 

1  case.  After  removal  of  sarcoma  of  axilla.     Septicaemia,  20th  day. 

1  case.  After  sarcoma  (supposed  aneurism).     Hemorrhage,  2,oth  day. 

lease.  After  removal  of  mamma  (sarcoma  ?).     Pleuritis,  3d  day. 

lease.  After  removal  of  humerus.     Carcinoma.     Septicaemia,  5th  day. 

1  case.  After  removal  of  humerus.     Carcinoma.     Exhaustion,  3d  day. 

1  case.  After  removal  of  tumor  in  axilla.  ?  ? 

1  case.  After  fungus,  axilla  (supposed  aneurism).    Exhaustion,  ? 

1  case.  After  malignant  tumor  of  axilla.     Phlebitis,  6th  day. 

17  Total. 
The  15  cases  of  recovery  under  the  above  heading  are  given 
below. 

Cases  of  recovery.     Cause  of  operation,  etc.: — 

1  case.     Amputation  for  encephaloid  of  humerus. 

1  case.     Eemoval  of  clavicle  and  scapula  for  osteo-sarcoma  (No.  91). 

1  case.     Removal  of  head  of  humerus  and  scapula  ;  cancer. 

1  case.     Eemoval  of  sarcoma  of  axilla. 

1  case.     Removal  of  carcinoma  of  axilla. 

1  case.     Osteo-sarcoma.     Supposed  aneurism.     Recovered,  not  cured. 

2  cases.     After  ligature  of  brachial  for  aneurism. 
2  cases.     After  opening  abscess  in  axilla. 

2  cases.     Amputations  for  railroad  crush. 
1  case.    After  resection  of  humerus  for  fracture. 
1  case.     After  excision  of  humerus  for  fracture. 
1  case.    Ulceration  of  amputated  stump. 

15  Total. 


238 


PRIZE     ESSAY. 


Out  of  32  cases  coming  under  the  above  caption  17  were  fatal,  or 
53  per  ct.  (It  is  worthy  of  note  that  of  the  15  recoveries,  6  were  in 
connection  with  malignant  diseases.) 

Resume  of  Cases  of  Ligature  of  the  Subclavian  in  its  2>d  Division  on 
account  of  Hemorrhage. 

Gunshot  wounds         .... 
Lacerated  wounds      ... 
Punctured  wounds     . 

?  wound 

Hemorrhage  after,  or  on  account    of,  sur 

procedures' 

Total   .         .         . 
Or  a  death-rate  of  65  per  cent. 


Cases. 

Died. 

Recovered 

. 

49 

41 

8 

3 

2 

1 

13 

4 

9 

1 

0 

1 

irgical 

29 

15 

14 

95 

62 

33 

SUMMARY  OF  CASES  OF  LIGATURE  OF  THE  SUBCLAVIAIST  ARTERY  FOR 
ALL  LESIONS  EXCEPT  ANEURISM  AND  GUNSHOT  WOUNDS  IN  ITS 
FIRST,  SECOND,  AND  THIRD  SURGICAL  DIVISIONS. 

Under  this  head  there  are  52  cases  in  the  table,  with  27  recoveries. 
The  conditions  are  as  follows  : — ■ 

Cured  with  no  remaining  lesion 20 

Cured  with  amputation  of  scapula,  clavicle,  and  humerus  for  osteo- 
sarcoma          .  1 

Cured  with  amputation  at  shoulder  (punctured  wound)      .         .         .1 

Cured  with  amputation  at  upper  third  (railroad  accident)          .         .  1 

Cured  with  amputation  at  shoulder             ......  1 

Cured  with  resection  of  arm 1 

Case  not  cured  (tumor  still  persisting)       ......  1 

Reported  as  recovered,  no  mention  made  of  condition        ...  1 

Total 27 

Resume. 

Ligature  in  the  third  Division  on  account  of  Aneurism. 
Under  this  head  I  have  made  a  summary  of  the  following  sub- 
divisions, viz. : — 

1st.    Subclavian  aneurism.^ 
2d.    Subclavio-axillary. 
3d.    Axillary. 

'  The  3  cases  of  "supposed  aaelTrism"  are  omitted  in  this  r/sumi. 

2  It  is  very  probable  that  all  of  these  cases  were  subclavio-axillary,  as  it  would  be 
difficult  to  tie  the  artery  in  its  third  division  for  aneurism  luvolving  this  portion 
alone. 


INNOMINATE    AND    SUBCLAVIAN    ARTERIES. 


239 


4tli.  Aneurism  on  distal  aide  of  ligature,  situation  not  given. 
5tli.  Aneurism  on  cardiac  side  of   ligature.      (Wardrop  as  sug- 
gested by  Brasdor.) 

For  Subclavian  Aneurism. 
Total  5  cases;  recovered,  2.     Of  tlie  3  fatal  cases  the  cause  of 
death  in — 

1  was  gangrene  and  exhaustion,  on  5tb  day. 
1  (probably  injury  of  thoracic  duct)  on     ? 
1  cause  not  given. 

Suhclavio- Axillary  Anenrism, 
Total  29  cases.     Died  13,  or  45  per  centum.     The  cause  and  date 
of  death  and  cause  of  aneurism  as  far  as  given  were  in  — 


1  case  exhaustion     . 
1  case  exhaustion     . 
1  case  exhaustion     . 
1  case  hemorrhage 
]  case  hemorrhage 
I  case  pleuritis,    pneumonia,   em- 
physema   . 
1  case  hemorrhage 
I  case  hemorrhage 
1  case  hemorrhage 
1  case  hemorrhage  and  pj-aemia 
1  case  pleuritis 
1  case  phlebitis  and  coma 
1  case  pneumonia   . 


5tli  day,  fall  from  horse. 

4th  day.         ? 

7th  day.         ? 
35th  day,  syphilis. 
29th  day,  carrying  weight  on  shoulder. 

15th  day.  ? 

12th  day,  rheunuitisra. 
65th  day,  rheumatism. 

?     day,  shot  wound. 
14th  day,  punctured  wound. 

3d   day.  ? 

22d    day,  fall. 
22d    day.     ? 


13  Total. 

Of  the  16  recoveries,  all  were  cured  but  one. 
In  8  cases  no  cause  of  disease  is  given. 
In  1  case  the  cause  was  "  strain  while  drawing  a  cork  !" 
In  1  case  "  barrel  fell  on  shoulder." 
lu  1  case  "  struck  with  rope." 
In  1  case  shot  wound  (military). 
In  1  case  (No.  147)  after  amputation. 
In  1  case  "  cask  fell  on  shoulder." 
In  1  case  shot  wound  (civil). 
In  1  case  idiopathic. 

Axillary  Aneurism. 
The  ligature  was  applied  in  the  third  division  on  account  of 
"axillary  aneurism"  in  75  cases,  with  47  recoveries;  the  death-rate 
being  37  per  cent.  As  far  as  given  the  following  is  a  synopsis  of 
the  causes  and  dates  of  death  and  the  cause  of  the  aneurism  in  the 
28  fatal  cases. 


2-iO 


PRIZE    ESSAY. 


1  case.  Exhaustion 

1  case.  Cerebral  symptoms    . 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Hemorrhage 

1  case.  Exhaustion  and  hemorr. 

1  case.  Exhaustion 

1  case.  Exhaustion 

1  case.  Exhaustion 

1  case.  Exhaustion 

1  case.  Exhaustion 

1  case.  Exhaustion  and  dyspnoea 

1  case.  Shock 

1  case.  Cause  unknown 

1  case.  Cause  unknown 

1  case.  Cause  unknown 

1  case.  Cause  unknown 

1  case.  Cause  unknown 

1  case.  Pyaemia    . 


5th  day.         ? 

8th  day,  traumatic. 
12th  day,  rheumatism. 

6th  day,  punctured  wound. 
15th  day,  punctured  wound. 
37th  day,  "  sack  of  beans  fell  on  shoulder." 
27th  day.  ? 

46th  day,  shot  wound. 

?  shot  wound. 

16  th  day.  ? 

62d   day.  ? 

42d    day,  "  rebound  of  cannon." 
33d   day,  reduction  of  shoulder. 
14th  day,  shot  wound. 
60th  day.  ? 

30th  day,  fracture  of  humerus. 
46th  day,  idiopathic  (opened  for  abscess). 
30th  day. 

2d   day,  shot  wound. 
12th  day,  shot  wound. 

6  hours,  shot  wound. 

4th  day. 

4th  day,  traumatic. 
?  pistol  wound  (civil). 

?  traumatic, 

several  days        ? 

?      thrust  of  pitchfork. 
18th  day.  ? 


28  Total. 
In  the  47  recoveries,  the  causes  of  the  aneurism  as  given  were — 

4  cases.  Idiopathic. 

7  cases.  Punctured  wounds. 

4  cases.  Shot  wounds  (2  civil  and  2  military). 

2  cases.  "  Fall." 

2  cases.  "  Strain." 

1  case.  "  Fall,  with  wound  and  dislocation  of  shoulder." 

1  case.  "  Fall  and  catching  by  arm." 

1  case.  "  Muscular  exertion." 

1  case.  "  Gored  by  cow." 

1  case.  "  Lifting  weight." 

1  case.  "  Thrown  from  carriage." 

1  case.  "  Traumatic." 

26  Total  given. 
In  addition  to  the  foregoing  there  were  12  cases  of  aneurism  be- 
yond the  seat  of  ligature,  the  vessel  involved  in  the  lesion  not  being 
given.     The  majority  (if  not  all)  of  these  were  no  doubt  aneurisms 
of  the  axillary ;  6  died  and  6  recovered. 


INNOMINATE     AND    S  L/  B  C  L  A  V  I  A  N    A  li  'I'  E  It  1  K  S , 


241 


The  cause  and  date  of  doatli,  and  cause  of  aneurism  were- 


I.  Ilc'iiiorrliiigu 

1.  i  l('in()rrliii<,^c 

1.  JIcinorrlia<;o 

1.  KxlituiHtion  .... 
].  ?  .         .         .         . 

1.  Iiifiammatioii  of  kiic,  plciiritis, 
and  pericarditis 

Causes  of  aneurism  in  the  6  cases  of  recovery 
3  cases.   Cause  not  given. 
1  case.     Punctured  wound. 
1  case.     Pistol-sliot  wound  (civil). 
1  case.     Dislocation  or  reduction  of  shoulder. 


7tii  day,  sliot  wound  (civil), 
ll'itli  day,  Iranmatic. 
Hevei'al  days,  dislocation  (subglenoid). 
4tli  day.  V 

?  ? 


7 til  day. 


SYNOPSIS    OF    CASES    OP    LIGATURE    OF    THE    SUBCLAVIAN    IN   ITS    uD 

DIVISION,    FOR    ANEURISM    BETWEEN    THE    LIGATURE    AND    THE 

HEART. 

(Wardrop's  operation,  after  suggestion  of  Brasdor.) 

1.  Ligature  of  subclavian  alone. 
•    2.  Ligature  of  subclavian  and  the  right  common  carotid. 

Ligature  of  Subclavian  alone. 
1  case  (No.  61.     Wardrop).     Recovered,  temporarily  relieved. 
1  case  (No.  227.  Broca).  "  "  " 

1  case  (No.  237.  Bryant).  "  permanent  relief. 

Total  3  cases.  (Wardrop's  case  died  of  the  disease  2  years  later. 
Broca's  of  "pulmonary  gangrene."  Bryant's  case  was  alive  and 
doing  well  at  last  account.) 

The  following  cases  were  ligatures  of  the  3d  portion,  and  of  the 
carotid : — 

Operations  Simu'taiieous. 


Fatal  cases: — 

No.        Operator. 

246.  Durham. 

247.  Eliot. 

248.  Ensor. 
257.  Holmes. 

Hodges. 

Weir. 

Maunder. 


Seat  of  Aneurism.  Date  of  Death. 

Innominate.  6th  day. 

25 
Aorta  and  innominate.  65        " 
Innominate.  57       " 

11       " 
11       " 
"  Few  days. 


Cause. 
Shock. 
Hemorrhage. 


260. 
279. 
283. 

Recoveries: — 

284.  Barwell,'  aortic,  carotid,  subclavian  and  innominate  aneurism. 

cure,  3  months  later  doing  well. 
276.  Sands,  aorta.     Died  13  months  later  from  the  aneurism. 


Probable 


'  Barwell's  case  died  three  months  after  operation.     (See  foot  of  page  100.) 

16 


242  PRIZE    ESSAY. 

259.  Heath,  innominate.     Died  4  years  later  from  the  aneurism. 
261.  Lane,  innominate.     No  improvement. 

270.  Little,  innominate  or  aorta.     Marked  improvement,  one  year  after  opera- 
tion doing  well. 

Cases  in  which   the  carotid   was  tied  at  a  previous  operation. 
Fatal  cases: — ■ 
242.  Bickersteth,  innominate  and  aorta.     21st  day,  suffocation.     Carotid  tied 

7  weeks  previously. 
280.  Wickham,  innominate.    Died  3  months.    (?)    Carotid  tied  about  3  months 

previously. 
282.  Speir,  aortic.    Died  32d  day,  hemorrhage.     Carotid  obliterated  by  "  con 
striction"  2  days  before. 

Recoveries: — 
255.  Fearn,  innominate.     Much  improved.     Carotid  tied  2  years  before. 
265.  A.  B.  Mott,  innominate.    Cured.    Carotid  tied  by  Doughty,  of  New  York, 

1  year  previously. 
Total  17  cases  ;  10  deaths  ;  7  recoveries. 

[On  a  previous  page  I  have  given  6  other  cases  of  the  double 
operation  (see  ISTos.  14  to  19  inclusive),  all  of  which  were  fatal, 
making  22  cases,  with  a  mortality  of  16,  or  73  per  cent.  Hemor- 
rhage was  the  cause  of  death  in  10  of  these  16  fatal  cases;  viz.,  from 
the  -sac  in  5  instances;  from  the  distal  end  of  the  subclavian  in  3; 
the  carotid  in  l;-and  rupture  of  the  internal  jugular  in  1  (Hodges). 
Hemorrhage  occurred  in  one  case  which  recovered  temporarily 
(Prof.  Sands).] 

A  GENERAL  SUMMARY  OF  CASES  IN  WHICH  THE  SUBCLAVIAN  ARTERY 
WAS  TIED  IN  ITS  IST,  2d,  AND  3d  DIVISIONS  ON  ACCOUNT  OF 
ANEURISM. 

Of  the  283  cases  of  ligature  of  the  subclavian  given  in  the  accom- 
panying "History,"  167,  or  59  per  cent.,  were  for  the  cure  of  aneu- 
risms. All  of  these  aneurisms  were  beyond  the  ligature  excepting 
21,  which  were  lesions  of  the  aorta,  innominate,  or  both. 

As  to  Sex. 
Of  the  167  cases,  the  sex  is  stated  in  153 ;  of  which  140  were 
males,  and  only  13  females  /  We  may  expect  (according  to  this 
ratio)  to  meet  with  12  males  with  aneurisms,  suggesting  ligature  of 
the  subclavian,  to  1  female.  It  is  an  interesting  fact,  that,  in  13 
females,  suffering  from  aneurisms  for  which  the  above  operation 
was  performed,  6  {or  one-half)  were  for  aortic  or  innominate  aneurism, 
the  ratio  in  males  being  only  1  in  13  cases. 


INISrOMIlSrATK    AND    S  IJ  IKJ  L  A  VI  A  N"    ARTICRIPJS,  243 

Of  tlie  21  cases  of  the  distal  operation,  the  sex  is  given  in  17,  of 
which  11  are  males  and  ^females.  All  of  the  females  recovered  hut 
one^  while  of  the  11  males  only  three  recovered.  It  is  clear  from  this 
that  the  distal  ligature  is  fuller  of  promise  in  females  than  in  the 
opposite  sex.  I  am  of  the  opinion  that  this  is  due  to  the  fact  that 
women  are  more  patient  and  obedient  under  treatment,  and  can  be 
kept  quieter  than  men. 

As  to  Side  of  Body. 

^he  side  is  designated  in  145  instances:  on  the  r?>//i^  in  89;  on  the 
left  in  56.  According  to  this  aneurism  will  exist  about  1-|  times 
on  the  right,  to  1  on  the  left  side. 

Of  the  entire  167  cases  of  aneurism,  85  recovered,  a  death-rate  of 
49  per  cent.  Of  these  85  recoveries  the  side  of  body  is  given  in  80, 
37  on  the  right  and  43  on  the  left. 

Since  the  artery  was  tied  on  the  right  side  in  89  given  cases,  with 
only  37  recoveries,  we  have  a  death-ratio  of  58.5  per  centum  on  this 
side ;  while  on  the  left  side,  out  of  56  given  cases  there  were  43  re- 
coveries, or  a  death-ratio  of  only  23.2  per  cent.,  a  difference  of  about 
35  per  cent,  in  favor  of  the  ligature  of  the  left  subclavian  artery. 
(This  difference  is  doubtless  in  great  measure  due  to :  1st,  the 
"Brasdor-Wardrop"  operations  being  on  the  right  side.  2d,  the 
greater  length  and  more  favorable  position  of  the  left  subclavian.) 

The  condition  after  recovery  on  the  right  side  is  as  follows : — 

Reported  permanently  and  completely  cured 24 

With  amputation  at  the  shoulder,  cured 1 

With  loss  of  use  of  hand  by  ulceration,  cured 1 

Aortic  or  innominate  aneurism  (distal),  "  improved"       ...  2 
"                   "                   "         "  improved"  (died,  4  years,  of  aneu- 
rism)        1 

Aortic  or  innominate  aneurism,  "  improved"    (died,    13  months,   of 

aneurism) .  1 

Aortic  or  innominate  aneurism,  "  no  better" 1 

"  "  "  "  improved,"  died,  few  months,  of 

pulmonary  gangrene 1 

Aortic  or  innominate  aneurism,  "  improved"    (died  in  3  months  of 

pleuritis I 

Aortic  or  innominate  aneurism,  "  temporary  relief,"  died  in  2  years 

of  aneurism 1 

Contents  of  sac  remained  fluid  for  some  time 1 

Aneurism  persisted  5  years  after  operation 1 


2M 


PRIZE    ESSAY. 


Of  the  conditions  on  the  left  side,  in  43  cases 

Cured  without  any  injury  or  lasting  deformity 
"       Avith  amputation  at  shoulder  (gangrene) 

(fall) 
"  '  "  upper  3d  (pistol  shot) 

"       partial  anchylosis  of  elbow  (punctured  wound) 

"       (fall) 
"  "        disability  of  arm  (shot  wound)  . 

"       lost  two  fingers,  gangrene  (fall) 

Small  tumor  persisted  in 

Noted  as  recoveries,  cure  not  reported     . 


32 
1 
1 
1 
1 
1 
1 
1 
1 
3 

43 


It  will  be  seen  that  not  onlj  are  the  chances  for  recovery  greater 
after  ligature  of  the  left  subclavian  for  aneurism,  but  that  the 
recovery  is  more  apt  to  terminate  in  a  complete  cure  than  upon  the 
right  side. 

Conclusions  as  to  Ligature  of  the  Sid'clauian  Artery  in  its  third 
Surgical  Division. 

1.  That  in  gunshot  wounds  of  the  axillary  region,  the  ligature 
of  the  subclavian  is  fraught  with  danger  from  secondary  hemorrhage 
after  the  establishment  of  the  collateral  circulation.  That  ligature 
in  the  seat  of  injury,  upon  both  sides  of  every  bleeding  vessel  (in 
this  as  in  all  other  lesions)  without  regard  to  the  extent  of  the  in- 
cisions necessary,  should  be  the  practice.  That  wounds  thus  made 
in  the  track  of  the  original  wound  should  be  left  freely  open  for 
drainage.  That  in  case  the  tumefaction  or  any  accidental  condition 
of  the  part  injured  should  render  the  operation  at  the  seat  of  lesion 
impossible,  then  the  subclavian  should  be  tied  in  its  third  division, 
the  posterior  scapular  sought  for  and  tied  (if  present).  Two  ligatures 
should  be  placed  upon  the  subclavian,  the  vessel  divided  between 
them,  and  torsion  practised  with  both  ends. 

2.  That  in  all  lesions  causing  dangerous  hemorrhage,  while  the 
danger  of  death  does  not  exist  to  such  an  alarming  extent  as  in 
gunshot  wounds,  the  same  operative  procedures  should  be  practised 
as  in  the  foregoing  class  of  cases,  subject  to  the  same  exceptions. 

3.  In  aneurisms  of  the  axillary  region,  the  ligature  (which  is  fatal 
in  40+  per  cent.)  should  not  be  attempted  until  a  persistent  trial  is 
made  of  the  various  methods  recommended  under  the  head  of 
"  Aneurisms  of  the  First  Surgical  Division."  Digital  or  mechanical 
pressure  as  the  vessel  crosses  the  first  rib,  in  connection  with  Val- 
salva's method,  rest  on  the  back,  gentle  pressure  directly  upon  the 


INNOMINATE    AND    SUBCLAVIAN    AltTKRIES.  245 

tumor,  if  undertaken  with  a  determination  on  the  {)art  of  both  sur- 
geon and  patient  to  succeed,  will  ([  believe)  fail  so  rarely  that 
ligature  of  the  subclavian  will  not  be  necessary  in  the  great  majority 
of  cases.  Should  however  the  necessity  arise,  the  same  rules  are 
applicable  as  heretofore  given. 

4.  Simultaneous  ligature  of  the  subclavian  and  carotid  arteries 
for  relief  of  aneurism  on  c«n/i«c  side  of  these  ligatures  (Brasdor- 
Wardrop)  is  of  questionable  propriety.  I  would  advise  that  the 
conservative  methods  given  (and  illustrated  in  the  successful  cases) 
heretofore  be  courageously  and  persistently  tried.  Should  these 
fail  and  deligation  be  determined  upon,  the  carotid  should  be  first 
tied,  and,  after  an  interval  of  some  weeks,  the  subclavian,  in  its  third 
division  (subject  to  the  rules  laid  down  in  the  operative  surgery, 
which  see). 

The  subclavian  should  not  be  tied  first,  since  the  danger  of  an 
embolus  being  carried  into  the  cranial  circulation  would  be  thus 
increased. 


Fig.  1. 


c  % 


fl  ,2 


H  a 


^    o 


to    fc 


tc  pS    ^ 


y2 

CO 

^ 

"aj 

3J 

c3 

* 

> 

S 

t« 

c3 

"S 

^ 

b 

N.^ 

to 

t^ 

Si 


Fig.  2. 


Range  of  origin  of  the  right  and  left  vertebral  and  internal  mammary 
arteries  (deduced  from  52  consecutive  dissections).  (Figure  reduced 
from  life-size  drawing.) 


Fiq.  3. 


Suprascapular 
Supr.  Intercostal 

Int.  Mammary    ' 
Comes  Nervi  Phr.  - 


"-  Suprascapular 

Int.  Mammary 

Supr.  Intercostal 


CORONARY- 


Occasional  abnormal  positions  of  the  branches  of  the  subclavian  arteries. 
(Reduced  from  life-size  drawing.) 


Fig.  4. 


Range  of  origin  of  the  inferior  thyroid,  posterior  scapular,  and  superior 
intercostal  branches  of  the  right  and  left  subclavian  arteries.  De- 
duced from  52  consecutive  dissections.  (Reduced  from  life-size 
drawings.) 


Fig.  5. 


Level  with  Top 


of  Stovuum 


ST"     OriginofRiirht  Subclavian 


Arch  of  the  Aorta. — Relations  of  the  great  vessels  when  the  riglit  snbulavian  is 
derived  from  the  descending  portion  of  the  arch.  (Reduced  from  a  life-size 
drawing.) 


THE  SURGICAL  ANATOMY 


TIBIO-TARSAL  REGION,' 

WITH  SPECIAL  REGAED   TO   AMPUTATIONS  AT  THE   ANKLE-JOINT,  AS  DEDUCED 
PKOM  EIGHTY-SEVEN  CONSECUTIVE  DISSECTIONS. 


DIAGRAM  SHOWING  THE  AKTERIAL  SUPPLY  TO  THE  CALCANEAK  REGION,  ON  THE  TIBIAL  SIDE  OF 
THE  FOOT DRAWJf  BY  THE  AUTHOR,  FROM  THE  AVERAGE  OF  EIGHTY-SEVEN    DISSECTIONS. 


M. — Interual  Malleolus. 

PMCN. — Tibio- tarsal  Quadrilateral,  tlie  Surgical 

reg-ion  of  this  Articulation. 
K. — Posterior  Tibial  Artery. 
O. — Its  point  of  bifurcation  into 
G. — Internal  Plantar  and 
F. — External  Plantar  Artery. 
III. — Calcaneau  Branches  of  External  Plantar. 
T. — Articular  Branches  from  Posterior  Tibial. 
H. — Articular  Branch  from  Internal  Plantar. 
Q. — Tendon  of  Tibialis  Posticus  Muscle. 


E. — Tendon  of  Flexor  Longus  Digitorum. 

S. — Tendon  of  Flexor  Longus  PoUicis. 

MC. — The  line  of  incision  of  Gross. 

ML,  MD,  ME,  ME.— Lines  of  incision  showing 
that  the  nearer  the  incision  approaches  the 
heel,  the  more  danger  is  incurred  of  cutting 
off  the  principal  blood  supply  to  the  Calca- 
nean  Flap,  in  amputation. 

MN. — Line  crossing  the. usual  point  of  bifurca- 
tion of  the  Posterior  Tibial. 

MA,  MB. — Anterior  incision. 


•  Reprinted  from  American  Journal  of  Medical  Sciences,  April,   1876. 

This  Essay  was  awarded  the  Annual  Prize  of  One  Hundred  Dollars,  offered  by  Prof  Jnmes 
R.  Wood,  to  the  Alumni  Association  of  the  Bellevue  Hospital  Medical  College,  for  "The 
best  Essay  on  any  subject  connected  with  Surgical  Pathology  or  Operative  Surgery,"  Febru- 
ary, 1876.  The  Committee  were  Professors  W.  H.  Van  Buren,  Austin  Flint,  St.,  and 
Alpheus  B.  Crosby. 

(247) 


2'18  PRIZE     ESSAY. 

In  botli  the  amputations  at  the  tibio-tarsal  articulation  (Syme's 
and  Pirogoff''s),  surgeons  agree  that  the  perfect  success  of  the  ope- 
ration depends  upon  the  vitality,  i.  ?.,  the  non-interference  with  the 
blood  supply  of  the  inferior  or  calcanean  flap. 

D(5scriptive  and  surgical  anatomists  and  operative  surgeons  agree, 
with  remarkable  unanimity,  that  the  integrity  of  this  flap  is  depend- 
ent upon  its  blood  supply,  partly  from  the  anterior  and  posterior 
peroneal  arteries^  on  the  outer  side,  but  principally  from  the  calcanean 
branches  of  the  posterior  tibial  on  the  inner  side  of  the  ankle-joint. 

In  reference  to  this.  Gross  says:  "Care  should  be  taken  not  to 
wound  the  posterior  tibial  prior  to  its  separation  into  its  plantar 
branches,  otherwise  sloughing  of  the  soft  parts  might  ensue  from 
deficient  nourishment;"  while  Yalentine  Mott,  in  his  edition  of  Vel- 
peau''.5  Surgery  {c[uoting  from  Syme),  uses  almost  the  same  language: 
"Both  incisions  should  be  continuous,  and  exactly  opposite  to  each 
other.  Care  should  be  taken  not  to  cut  the  posterior  tibial  before  it 
divides  into  the  2)Ia7itars,  as  in  two  instances  when  this  happened 
(to  Mr.  Syme)  there  was  partial  sloughing  of  the  flap." 

Erichsen  says,  "unless  care  be  taken  to  cut  the  plantar  arteries 
long,  the  flap  will  be  insufficiently  supplied  with  blood,  and  slough- 
ing, especially  of  its  outer  angle,  will  be  likely  to  occur;"  and  Ham- 
ilton, in  the  same  connection,  writes,  "  the  operator  must  not  wound 
the  posterior  tibial  before  it  has  given  off'  the  internal  calcanean 
branches.  Division  of  the  posterior  tibial  at  a  point  loioer  than  this 
does  not,  as  has  been  affirmed,  endanger  the  vitality  of  the  fiap^  as  it 
receives  no  arterial  supyply  from  a  lower  source^^ 

Holmes  is  of  the  opinion  that  "the  integrity  of  the  j'^osterior  tibial, 
though  desirable,  is  by  no  means  essential,  provided  the  rest  of  the 
subcutaneous  tissue  has  been  left  uninjured."^ 

Apropos  to  the  generally  accepted  idea  of  the  origin  of  this  prin- 
cipal blood  supply,  the  following  quotations  are  given:  — 

"The  m/erna I?  calcanean  consist  of  several  large  branches  which 
arise  from  the  posterior  tibial  ^ust  before  its  division." — Gray. 

Quain,  while  mentioning  these  vessels  in  his  text  only  in  a  gene- 

•  The  italics  are  the  writer's,  not  Prof.  Hamilton's. 

2  Laying  no  claim  to  personal  experience,  the  author  cannot  understand  how  it 
would  be  possible  to  dissect  out  a  bone  so  full  of  iniientatioiis  and  rough  eminences, 
so  covered  with  the  insertions  and  origins  of  ligaments  and  muscles,  and  sheaths, 
through  which  tendons  play,  and  leave  "the  subcutaneous  tissue  uninjured."  There 
are  no  less  than  thirteen  muscles  in  relation  to  this  dissection,  to  say  nothing  of 
ligaments. 


TIBIO-TAKSA  T.    REfilON.  249 

ral  wn,y,  gives  them  specially  in  liis  diagrams  as  branches  from  the 
jMsterior  tibial^  anastomosing  vvitli  branches  of  the  'imsti'Tior  peroneal. 

^^T\\(d  rnlernal  calcancxtn  hran.rJi.eH,  three  or  four  in  nurnber,  [)ro- 
ceed  {'You\i\\Q  posterior  tihud  artery  itninediatiiiy  before  its  division." 
—  Wilson. 

"Tlie  cahanean  arteries  are  two  or  three  branches  from  the  lower 
part  of  the  posterior  tibial.^'' — Leidij. 

"Under  the  arch  of  the  calcaneum  the  pos^er/or  ^i'/^itt^  gives  origin, 
1st,  to  branches  distributed  to  the  periosteum,  to  the  adductor  (?)  of 
the  great  toe,  the  short  flexor  of  the  toes,  and  to  the  superficial 
structures;  and,  2d,  to  other  branches  of  less  calibre,  which  mount 
the  inner  border  of  the  foot,  to  anastomose  with  descending  branches 
of  the  internal  malleolar  branch  of  the  anterior  iibial.^^^ 

Hyrtl  mentions  the  operation  of  amputation  at  the  ankle  joint, 
but  does  not  consider  the  surgical  anatomy  relating  to  this  pro- 
cedure. 

I  assert,  without  equivocation,  that  the  arterial  supply  to  the  calca- 
nean  region,  as  given  above,  is  not  correct,  in  the  main;  and  that 
the  operative  surgery  at  the  ankle-joint,  based  upon  the  idea  that 
the  arterial  supply  to  the  caleanean  flap  is  derived  from  the  poste- 
rior tibial,  is  unsafe. 

Having  failed  to  find  this  distribution,  as  given  in  the  text-books 
some  years  ago,  I  determined  to  investigate  this  matter  thoroughly, 
and  to  that  end,  made  80  consecutive  dissections  of  this  region,  with 
all  requisite  care,  the  result  of  which  is  given  in  the  table  and  re- 
sume appended  to  this  essay. 

In  72  of  80  cases  the  posterior  tibial  bifurcated  into  its  plantar 
branches  on  a  line  between  the  lower  border  of  the  inner  malleolus 
and  the  middle  or  centre  of  the  heel's  convexity.  In  four  of  the 
remaining  cases,  the  separation  occurred  one-fourth  of  an  inch,  and 
in  the  other  four  cases  one-half  an  inch  heloial\i\s  line  M  N  {see  dia- 
gram). Any  variations^  in  the  point  of  division  tend,  in  all  cases, 
toward  the  line  of  incision  in  amputations  in  this  region. 

In  38  out  of  80  dissections  {almost  one-half)^  there  was  not  a  single 
caleanean  artery  derived  from  the  posterior  tibial  (K  0,  see  diagram). 

1  Sous  le  voute  du  calcaneum  la  tibuile  posterieure  donne  naissauce ;  1°,  a  des  ra- 
iiieaux  qui  se  distribuent  au  perioste,  an  muscle  adducteur  du  gros  orteil,  au  court 
flechisseurcommuudes  orteil,  et  aux  teguments  ;  2",  a  d'auties  rameaux  d'un  moindre 
calibre  qui  remoutent  sur  le  bord  interne  du  pied  pour  s'anastomoser  avef  des  ra- 
meaux descendants  de  la  malleolaire  interne,  brauclie  de  la  tibiale  anterieure. — 
Sappei], 


250  PRIZE    ESSAY. 

So  it  must  follow  that  any  line  of  incision  that  approximates  the 
terminal  bifurcation  of  this  vessel  will,  in  a  great  many  cases,  en- 
danger the  blood  supply,  and  consequently  the  success  of  the  ope- 
ration'. 

I  cannot  think  that  the  exceptional  cases  in  which  good  recov- 
eries have  resulted,  after  division  of  this  vessel,  above  or  at  its 
bifurcation,  are  arguments  of  any  weight  in  favor  of  the  incision 
"well  back  toward  the  heel,"  when  compared  with  the  fact  that,  in 
such  a  great  proportion  of  cases,  there  is  no  blood  supply  above 
this  point  to  the  inner  side  of  the  flap,  and  that  in  some  recorded 
cases  where  this  accident  has  happened,  dangerous  sloughing  has 
occurred. 

From  the  standpoint  of  surgical  anatomy,  the  incision  recom- 
mended and  practised  by  Prof.  Gross,  and  represented  in  the  annexed 
diagram  by  the  line  M  C,  is  the  most  rational,  since  it  is  farthest 
removed  from  the  most  constant  blood  supply  to  this  inferior  flap, 
viz.,  the  calcanea7i  branches  of  the  external  plantar  artery. 

In  80  cases,  51  calcanean  branches  were  derived  above  the  bifur- 
cation. 

In  80  cases,  18  were  derived  opposite  this  point. 

While  out  of  80  cases  the  number  of  calcanean  branches  derived 
from  the  external  plantar  artery,  and  distributed  to  the  posterior  or 
calcanean  flap,  safely  within  the  line  of  incision  of  Gross  (M  C)  given 
above,  was  221,  or  more  than  three  times  in  number,  and  carrying, 
without  the  least  exaggeration,  twice  the  volume  of  blood  of  those 
derived  opposite  to  and  above  the  bifurcation. 

Erichsen  in  his  text  says:  "It  is  of  importance  that  the  incision 
across  the  heel  should  be  carried  well  back  over  its  point.  Unless 
this  be  done,  a  large  cup-shaped  cavity  will  be  left,  in  which  blood 
and  pus  will  accumulate,  and  retard  the  cicatrization  of  the  stump. 
The  principal  point  to  be  attended  to,  however,  is  that  the  pla^itar 
arteries  be  cut  long." 

These  two  propositions  I  hold  as  anatomically  incompatible.  The 
arteries  will  be  cut  short,  dangerously  short,  if  the  incision  is  carried 
"well  back  over  the  point  of  the  heel,"  while  the  great  danger  of  re- 
tardation of  healing,  on  account  of  retained  septic  matter,  might  be 
obviated,  by  leaving  the  wound  open  for  drainage  at  its  most  depend- 
ent part,  or  cutting  a  drainage  hole  in  the  under  surface  of  this 
cup-shaped  flap,  as  is  recommended  by  surgeons  of  experience. 

In  fact,  strict  attention  to  cleanliness  should  render  the  collection 
and  absorption  of  septic  matter  impossible. 


TIBIO-TARSAL    REGION.  251 

IlamiUon,  agreeing  with  Eriobsen,  pcrliaps  a  little  more  emphatic 
in  his  method  of  expressing  it,  says:  "^J'he  ]ir)es  of  this  second  inci- 
sion ought  not  to  fall  vertically  from  the  malleoli;  that  is,  not  at 
right  angles  with  the  sole  of  the  foot,  as  this  would  give  a  redun- 
dancy of  flap;  it  would  also  iii-crease  the  danger  of  sloughing,  etc. 
It  is  better  to  carry  the  lines  of  incision  from  the  two  mal- 
leoli a  little  backwards,  so  that  the  knife  will  cross  the  bottom  of 
the  foot  about  an  inch  and  a  half  further  back;  and,  in  the  case  of 
an  unusually  long  heel,  it  will  be  proper  to  carry  the  incision  back- 
wards two  inches."  And  in  the  same  connection  as  quoted  before, 
he  adds:  "The  operator  must  not  wound  the  'posterior  tibial  artery 
before  it  has  given  o?f  the  internal  ccdcctnean  branches,  which  supply 
the  cellulo-adipose  tissue  and  integument  composing  the  posterior 
flap.  Division  of  the  posterior  tibial  at  a  point  lower  than  this  does 
not,  as  has  been  affirmed,  endanger  the  vitality  of  the  flap,  as  it 
receives  no  arterial  supply  from  a  lower  source." 

The  language  of  this  eminent  surgeon  is  decisive  and  emphatic. 

In  38  of  80  dissections^  there  ivas  not  an  artery  that  I  could  find,  by 
careful  dissection,  derived  from  the  posterior  tibial  and  distributed  to  the 
calcanean  region,  ivhile  in  every  case  of  80  dissections  there  ivas  one  or 
more  branches  derived  from  the  external  plantar,  and  distributed  directly 
to  this  part. 

Lister,  author  of  the  chapter  on  amputations  in  Holmes''s  Surgery, 
advises  that  "the  calcanean  incision  be  made  either  vertical  to,  or 
sloping  towards  the  heel,  commencing  at  the  tip  of  the  external  mal- 
leolus, and  going  under  the  foot  to  a  point  considerably  below  and 

behind  the  tip  of  the  inner  malleolus Even  the  integrity  of 

the  posterior  tibial  artery,  though  desirable,  is  by  no  means  essen- 
tial, provided  the  rest  of  the  subcutaneous  tissue  has  been  left 
uninjured."^ 

The  great  unevenness  of  the  os  calcis,  its  peculiar  shape,  covered 
with  the  attachments  of  muscles,  sheaths,  and  ligaments,  renders  it 
anatomically  difficult  to  be  dissected  out  in  this  operation,  without 
wounding,  more  or  less,  the  subcutaneous  tissue,  upon  which,  Mr, 
Lister  says,  the  integrity  of  the  flap  depends.  Moreover,  if  the 
"integrity  oi  the  posterior  tibial  is  not  essential,"  why  does  this  gen- 
tleman recommend  so  positively  an  incision  that  must  always  save 
this  vessel  to  the  operation?  Why  not  cut  an  "inch  and  a  half,  or, 
in  the  case  of  a  long  heel,"  two  inches  back  of  the  vertical  line  (as 

1  Holmes's  Surgery,  vol.  v.  pp.  643,  644. 


252  PRIZE    ESSAY. 

Hamilton  does),  where  he  would  have  plenty  of  flap  and  an  easier 
dissection  ? 

The  language  of  these  two  phases  of  his  operation  is  irrecon- 
cilable, and  the  assertion  that  "the  integrity  of  the  posterior  tibial 
artery,  though  desirable,  is  not  essential,"  is  not  strictly  in  accord- 
ance with  the  clinical  history  of  this  amputation,  and  is  utterly  at 
variance  with  the  anatomy  of  the  blood  supply  to  the  calcanean 
region. 

Stephen  Smith,  in  his  comprehensive  report,  says  the  necessity 
for  re-amputation  in  this  operation  is  three  per  cent,  greater  than  in 
any  other. 

Perhaps  the  cause  of  this  may  arise  from  the  reckless  sacrifice  of 
the  arterial  supply  to  this  region,  sanctioned  by  such  eminent  sur- 
geons as  I  have  quoted. 

The  writer  of  this  essay,  deeming  it  unnecessary  to  introduce  any 
further  quotations  and  comments,  since  he  wishes  to  be  concise, 
sinjply  begs  leave  to  state  that  he  has  entrusted  his  work  to  no  one; 
that  he  measured  every  dissection  with  accuracy,  and  noted  it  on 
the  spot;  and  that,  in  differing  so  widely  in  his  results  and  conclu- 
sions with  gentlemen  of  such  eminence  (whom  it  seems  almost  sac- 
rilege to  contradict),  he  reiterates  his  assertion  that  the  surgical 
anatomy  of  this  region  has,  heretofore,  7iot  been  correctly  described. 


TIBIO-TAKSAL    REGION. 


253 


T  ABLE 


SIIOWINft  ORIGIN  OF  THK  OAI,(!ANKAN  BIIANCIIKS  Or  TIIK  I'OSTKKIOIi  TIKIAI. 

AND  KXTKRNAI.  I'l.ANTAH  AUTKUIKS,  AH  DF.DIH'.KI)  PKOM  NOTKS 

ON  KiailTY  CONSECUTIVK  JJIHSKCTIONS. 


Number. 

Number  of  Calcanoan 
Briuichos      derived 
from    tlio   Posterior 
Tibial  Artery. 

NiiiMber  of  Calcaneal! 
Briiiiclios      derived 
opposite  tlie  Termi- 
nal   Uifurcatioii    of 
the  PoHtorior  Tibial. 

Number  of  Calcancaii 
HranchoH      derived 
from    the    External 
1' la  11  tar  Artery 
witliin     l]/^    iucbet 
of   itH  orit^in. 

1 

0 

0 

3 

2 

1 

0 

3 

3 

0 

0 

3 

4 

0 

0 

7 

5 

0 

0 

4 

6 

2 

0 

5 

1 

0 

1 

4 

8 

1 

0 

2 

9 

0 

0 

1 

10^ 

i 

0 

3 

11 

0 

0 

1 

W 

1 

0 

3 

13 

1 

0 

4 

14 

0 

0 

4 

15 

1 

0 

3 

16 

1 

0 

3 

n 

0 

0 

4 

18 

1 

0 

2 

19 

0 

0 

3 

20 

1 

1 

3 

21 

1 

1 

2. 

22 

1 

0 

2 

23 

0 

0 

2 

24 

0 

0 

3 

25 

0 

0 

2 

26 

0 

1 

2 

2Y 

1 

1 

4 

28 

1 

1 

1 

29 

1 

0 

2 

30 

1 

0 

2 

31 

0 

0 

o 
o 

32 

1 

1 

2 

33 

1 

0 

3 

34 

2 

0 

2 

35 

1 

1 

2 

36 

0 

0 

3 

,  37 

0 

0 

6 

38 

1 

0 

2 

39 

I 

0 

3 

40 

0 

1 

1 

'  This  case  bifurcated  one-half  iucb  lower  than  usual. 
2  This  case  bifurcated  one-half  inch  lower  than  usual. 


21 

)4 

PRIZE 

ESSAY. 

Number. 

Number  of  Calcanean 
Branches      derived 
from  the   Posterior 
Tibial  Artery. 

Number  of  Calcanean 
Branches      derived 
opposite  the  Termi- 
nal   Bifurcation    of 
the  Posterior  Tibial. 

Number  of  Calcanean 
Branches      derived 
from    the    External 
Plantar  Artery 
within    IJ^    inches 
of   its   origin. 

41^ 

2 

0 

2 

42 

1 

0 

3 

43 

1 

0 

2 

44 

0 

0 

3 

45 

0 

1 

2 

46 

0 

1 

4 

47 

0 

0 

2 

48 

1 

0 

3 

49 

2 

0 

2 

50 

0 

0 

3 

51 

0 

0 

3 

52^ 

1 

0 

2 

53 

2 

0 

6 

54 

1 

I 

4 

55^ 

0 

0 

3 

56 

2 

0 

0 

57 

1 

0 

1 

58 

0 

1 

3 

59 

0 

0 

2 

60* 

2 

0 

1 

61 

1 

0 

2 

62^ 

2 

0 

2 

63 

1 

0 

3 

64« 

0 

0 

3 

65 

1 

1 

3 

66 

0 

0 

3 

67 

0 

2 

1 

68 

0 

0 

3 

69 

1 

0 

4 

70 

0 

0 

3 

71 

1 

0 

3 

72 

1 

0 

2 

73 

2 

0 

2 

74 

0 

1 

4 

75 

0 

0 

4 

76 

0 

0 

3 

77 

1 

0 

3 

78 

0 

0 

5 

79 

0 

0 

2 

80 

Total     .     . 

0 

1 

1 

51 

18 

221 

This  case  bifurcated  one-fourth  inch  lower  than  usual. 
This  case  bifurcated  one-fourth  inch  lower  than  usual. 
This  case  bifurcated  one-fourth  inch  lower  than  usual. 
This  case  bifurcated  one-half  inch  lower  than  itsual. 
This  case  bifurcated  one-half  inch  lower  than  usual. 
This  case  bifurcated  one-fourth  inch  lower  than  usual. 


T  n?  I  O  -  T  A  liS  A  L     R  K  (i  ION.  255 

Summary  ON  the  Suiuiical  Anatomy  of  tiik  AiiTKiuAi.  Shj'I'ly 

TO    THE    TiBIO-TaRSAL    ItKOION,    AS     DEDUCED    EJiOM    80    DISSEC- 
TIONS. 

In  72  of  80  cases  the  posterior  tibial  artery  bifurcated  into  the 
external  and  internal  plantar,  on  a  level  with  a  line  drawn  i'vom  the 
most  dependent  portion  of  the  internal  malleolus,  to  tiie  middle  of 
the  heel's  convexity.     {See  M  N,  fig.  1.) 

In  4  of  80  cases,  this  bifurcation  occurred  -|-  inch  below  this  |)oint. 

In  4  of  80  cases,  it  was  |  inch  below  this  point;  any  variation 
from  the  usual  point  of  division  tending,  in  my  experience,  mva- 
riahly  (hionivard. 

Although  anatomists  give  the  arterial  supply  to  the  calcanean 
region  {internal  calcanean  arteries)  as  coming  from  the  |:>o.s^f?-wr  tibial 
artery  (as  shown  in  extracts  given  heretofore),  the  resume  of  tabu- 
lated dissections  shows  that,  out  of  a  total  of  80  cases,  in  38  there 
was  not  a  single  calcanean  branch  derived  above  the  termincd  bifurcation 
of  the  posterior  tibial  artery^  while  in  all  of  these  80  dissections,  one 
or  more  good-sized  ccdcanean  arteries  were  derived  from  the  external 
plantar^  within  one  and  a  quarter  inches  of  its  origin. 

In  80  cases,  the  number  of  ccdcanecm  arteries  derived  from  the 
posterior  tibial  was  51. 

In  80  cases,  18  branches  were  derived  opposite  the  point  of  bifur- 
cation, and  distributed  to  this  region. 

In  80  cases,  the  number  of  calcanean  arteries  derived  from  the 
external  plantar  was  221,  and  every  one  of  these  was  safely  inside 
the  line  of  incision  in  amputations  at  the  ankle-joint,  when  that  in- 
cision is  not  more  than  one-half  inch  posterior  to  the  axis  of  the 
leg  {see  M  0,  fig.  1),  with  the  foot  at  right  angles  to  the  leg.  In  all 
cases,  ctrticidar  branches  are  derived  either  from  the  posterior  tibial 
or  inter7ial  plantar,  or  from  both.  In  some  exceptional  cases,  the 
internal  plantar  gave  off  small  branches  to  the  heel. 

The  anterior  flap  is  plentifully  supplied  in  all  instances  by 
branches  from  the  anterior  tibial,  especially  the  malleolar  arteries. 

The  anterior  and  posterior  peroneal  dLX&ixihutQ  branches  to  the  outer 
portion  of  the  calcanean  flap,  those  from  i\iQ  posterior  anastomosing 
with  the  calcanean,  branches  of  the  external  plantar,  and  with  those 
of  the  posterior  tibial,  when  they  are  present.  I  do  not  think  the 
branches  from  the  peroneal  arteries  sufficiently  large  to  supply  blood 
enough  to  maintain  the  integrity  of  the  calcanean  flap,  especially 
when  their  anastomoses  are  cut  off  by  section  of  the  posterior  tibial, 
or  of  its  plantar  branches,  too  near  their  origin. 


256  PRIZE    ESSAY. 

The  relation  of  the  jjosterior  tibial  artery  is  quite  constant  with 
the  two  muscles  between  which  it  runs;  the  flexor  longus  digitorum 
in  front,  and  the  flexor  longus  pollicis  behind.  The  most  reliable 
guide-to  this  vessel  is  its  pulsation;  but  in  the  event  the  tourniquet 
is  applied/the  thumb  should  be  placed  over  tlie  middle  of  a  line 
drawn  from  the  inner  malleolus  to  the  centre  of  the  heel's  convexity, 
while  the  four  lesser  toes  are  held  still  by  an  assistant,  the  surgeon 
moves  the  great  toe,  and  marks  the  point  at  which  he  feels  the  ten- 
don gliding  under  his  thumb.  The  tendon  of  the  longus  digitorum 
is  found  in  the  same  manner,  and  half-way  between  the  two  a 
curved  incision,  with  its  concavity  towards  the  malleolus,  will  be 
over  the  artery.  The  relations  of  the  veins  on  either  side,  and  of 
the  iwsierior  iihial  nerve  behind,  are  among  the  least  variable  features 
of  the  anatomy  of  this  region.  In  two  cases  I  have  seen  the  artery 
immediately  behind  the  inner  malleolus.  When  the  posterior  tibial 
is  small,  the  peroneal  branches  undergo  compensatory  enlargement. 

P.  S. — Since  closing  these  notes,  some  weeks  ago,  the  writer  has 
made  seven  additional  dissections  of  this  region,  with  the  following 
result : — 

In  4  out  of  7  cases,  calcanean  branches  originated  from  the  poste- 
rior tibial  artery — 1,  one  inch  ;  1,  one-half  inch,  and  2,  one  eighth 
of  an  inch  above  the  bifurcation. 

In  7  cases,  2  calcanean  branches  were  derived  opposite  the  bifur- 
cation. 

In  7  cases,  19  calcanean  branches  were  derived  from  the  external 
plantar,  within  one  inch  of  its  origin;  3,  within  one-sixteenth;  2, 
within  one-eighth;  1,  witiiin  one-fourth;  4,  within  one-half;  4, 
within  three-fourths,  and  5  within  one  inch  of  the  bifurcation. 
Articular  branches  were,  as  usual,  from  posterior  tibial  and  internal 
plantar. 

The  posterior  tibial  bifurcated  in  every  case,  as  usual.  {See  dia- 
gram.) 


N  O  T  E  S 


UPON    TIIK 


SURGICAL  ANATOMY  OF  THE  OBTURATOR  ARTERY/ 

THE  DIFFERENCE  OF  ITS  RELATIONS  IN  THE  MALE  AND  FEMALE,  "WITH  A  CONSID- 
ERATION OP  ITS  IMPORTANCE  IN  THE  OPERATION  FOR  RELIEF  OF  FEMORAL 
HERNIA — DEDUCED  FROM  TWENTT-SKVEN  CONSECUTIVE  DISSECTIONS  OF  THE 
ARTERIES  IN  THE  MALE,  AND  TWENTY-SIX  IN  THE  FEMALE  PELVIS. 


In  its  distribution  the  obturator  artery  is  simple  find  constant;  in 
its  origin  and  relations  there  is  no  artery  in  the  human  body  which 
presents  so  many  vagaries.  In  support  of  this  last  statement  it  will 
suffice  to  quote  from  some  of  the  standard  text-books  the  different 
opinions  of  different  anatomists  upon  this  artery. 

Quain  gives  its  origin  as  "  usually  from  the  posterior  trunk  of  the 
internal  iliac,  not  unfrequently  from  the  epigastric." 

Sappey  takes  a  different  view,  and  says  "from  the  hypogastric 
(anterior  trunk  of  internal  iliac),  sometimes  from  the  external  iliac, 
rarely  from  i\ie  femoral.'''' 

Leidy  is  of  the  opinion  that  it  "  is  a  branch  of  the  posterior  trunk, 
and  often  a  branch  of  the  anterior  trunk  of  the  internal  iliacJ^ 

Wilson  gives  it  "from  the  anterior  trunk;  frequently  from  the 
posterior  trunk  of  the  internal  iliac.'''' 

Gray  agrees  with  Wilson  verbatim,  adding  that  "in  2  of  3  cases  the 
obturator  arises  from  the  internal  iliac,  in  1  of  3J  from  the  epigas- 
tric, in  1  of  72  by  two  roots  from  both  vessels." 

Luschka,  "  from  anterior  trunk  of  internal  iliac ;  occasionally,  from 
external  iliac,  epigastric,  ov  femoralJ'' 

Velpeau  writes:  "An  examination  of  several  thousand  cadavers 
does  not  permit  me  to  say  that  the  obturator  artery  comes  from  the 
epigastric  in  1  of  3,  nor  5,  nor  10,  but  only  1  in  20."  (!) 

Tiedemann  says,  on  the  other  hand,  that  "you  may  expect  to  find 

'  New  York  Medical  Record,  October,  1877. 

17  ( 257  ) 


2-38 


PRIZE    ESSAY. 


the  oUurator  from  the  epigastric  in  1  of  3  cases,  this  variety  being 
more  common  in  the  female  than  in  the  onale.'^^ 

In  the  two  following  tables  I  have  given  the  analysis  of  58  dis- 
sections, made  in  order  to  contribute  something  of  certainty  to  the 
anatom)^  of  this  artery.  Thirteen  subjects  of  each  sex  were  chosen, 
and  both  sides  noted  as  they  were  dissected. 


FEMALES. 

MALES. 

6 

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R 
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130 
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(33 
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J  39 
140 
f41 
142 
(43 
(44 
J  45 
146 
f47 
148 
J  49 
150 
f51 
\52 
53 

1=^ 

R 
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Remarks. 

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I    8 

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ll2 
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(19 
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13^ 

In  Nos.  7  and  8  the  ob- 
turator arclied  over  the 
crural   ring    in    such   a 
manner,  that,  had  femo-i 
rat  hernia  existed,  the 
intestine     might     have 
been   closely   encircled 
by  the  artery. 

One     origin      (quite 
small)     from    posterior 
trunk  ;  one,  larger,  from 
deep    epigastric ;    both 
united  in  obturator  ca- 
nal,  to    form    a    single 
trunk. 

1  The  writer  is  iudebted  to  Dr.  I.  Minis  Hays  for  valuable  reference  iu  regard  to 
this  artery  ;  to  "  Lawrence  on  Ruptures,"  one  of  the  most  valuable  books  on  this 
subject  published  ;  and  to  Dr.  W.  L.  Wardwell  for  assistance  in  taking  notes  of  the 
dissections. 

2  The  ^^—  to  the  left  indicates  the  dissections  to  have  been  made  upon  both  sides 
of  the  same  subject;  that  to  the  right,  that  the  origin  was  the  same  on  both  sides  of 
the  same  subject. 

Note. — In  8  other  dissections  in  which  the  sex  was  not  noted,  this  artery  came  from 
the  anterior  trunk  in  5,  from  the  posterior  in  1,  from  the  deep  epigastric  in  two  instances. 


OBTUKA'I'Oli    AKTEKV.  259 

It  will  be  seen  that  ]n  females,  of  26  cases,  the  ohturalor  was  from 
the  deep  cpiyantric  in  V6}^  instances;  from  the  posterior  trunk  of  the 
internal  iliac  in  1^-;   from  tiic  anterior  trunk  in  11   i)i,sl,aii(;(;s. 

In  males,  of  27  cases,  it  was  from  the  epigastric  in  only  5;  from 
\\\Q  posterior  trunk  in  1 ;  while  from  the  anterior  trunk  of  the  internal 
iliac  it  was  derived  in  22  instances. 

In  these  cases  it  is  seen  that,  in  females  we  may  expect  to  find  the 
obturator  to  be  derived  from  the  deep  epigastric  in  1  of  2  cases;  in 
males,  in  I  of  4|  cases. 

And,  in  a  total  of  61  cases,  regardless  of  sex,  the  proportion  is 
20,  or  1  in  8. 

Tiedemann  is  the  only  one  of  these  anatomists  who  notices  the 
difference  between  the  origin  of  this  vessel  in  males  and  females. 

In  160  cases  in  which  Cloquet  noted  the  obturator  as  coming  from 
the  internal  iliac,  87  were  in  males,  73  in  females,  showing,  as  in  my 
cases,  the  greater  tendency  of  this  vessel  to  come  from  the  internal 
iliac  in  men. 

In  56  cases  this  same  author  noted  from  the  epigastric,  21  were  in 
males,  35  in  females;  agreeing,  also,  with  the  dissections  embodied 
in  this  article,  that  the  tendency  of  the  obturator  to  come  from  the 
deep  epigastric  was  much  greater  in  women  than  in  men. 

So  great  is  this  difference,  that  the  estimates  made  from  both 
sexes  should  not  be  considered,  in  view  of  the  probable  contact 
with  this  vessel  in  femoral  hernia. 

An  examination  of  the  foregoing  tables  will  show  that,  in  19  of 
26  subjects,  this  artery  was  derived  from  the  same  point  on  the  two 
sides,  showing,  in  this  respect,  a  symmetry  of  arrangement  I  have 
not  noticed  in  any  other  artery  of  the  body. 

Femoral  hernia  being  comparatively  a  rare  accident  in  the  male, 
and  the  obturator  artery  having  a  dangerous  relation  to  the  femoral 
ring  in  the  male  sex  in  only  a  small  proportion  of  cases,  the  surgi- 
cal interest  of  this  vessel  belongs  to  the  opposite  sex. 

When  derived  from  the  epigastric,  it  usually  comes  off  from  this 
artery  from  |  to  f  of  an  inch  from  the  origin  of  the  epigastric  from 
the  external  iliac.  It  then  turns  abruptly  down  on  the  outer  side  of 
the  femoral  ring,  being  in  intimate  relation  with  the  sheath  of  the 
external  iliac  vein,  and  thus  makes  its  way  to  the  obturator  foramen 
in  such  a  manner  that  it  would  be  exceedingly  difficult  for  the  in- 
testine, descending  to  form  a  femoral  hernia,  to  insinuate  itself 
between  the  iliac  vein  and  the  obturator  artery,  so  as  to  loop  this 
latter  vessel  around  the  hernia.     This  danger  will  be  greater  as  the 


260  PRIZE    ESSAY. 

obturator  is  distant  at  its  origin  from  the  external  iliac.  However 
rare  this  double  accident  may  be  (femoral  hernia,  with  the  olturator 
artery  looped  around  it),  3^et,  as  it  can  and  has  occurred  in  several 
instances,  the  surgeon  should  proceed  in  every  case  as  if  he 
supposed  this  accidental  arrangement  existed. 

In  the  American  Journal  of  the  Medical  Sciences^  July,  1878,  p. 
269,  is  a  notice  of  a  case  in  which  death  resulted  from  division  of 
the  obturator  artery  in  an  operation  for  femoral  hernia  in  a  woman. 
The  vessel  was  from  the  epigastric,  |  an  inch  from  its  origin.  Mr. 
Barker  had  collected  12  cases  of  this  accident;  in  six  of  these  the 
vessel  was  secured  either  by  ligature,  or  with  a  hook.  Of  this  group 
2  died.  In  6  nothing  was  done,  and  only  one  died  (his  own  case, 
which  is  reported  as  dying  of  peritonitis).  "  At  the  autopsy,  3  or  4 
ounces  of  Mood  were  found  effused  under  the  peritoneum  in  the  pelvis." 
This  extravasation  may  have  caused  peritonitis  and  death.  It  is  to 
be  regretted  that  Mr.  Barker  does  not  say  what  proportion  of  these 
twelve  cases  were  females.  I  do  not  doubt  that  most  of  them  were 
of  this  latter  sex. 

When  the  stricture  is  so  situated  that  Gimbernat's  ligament  re- 
quires division,  the  point  of  the  probe  pointed  bistoury  should  be 
kept  hard  pressed  against  the  surface  of  the  os  pubis  to  which  this 
ligament  is  attached,  and  as  is  advised  by  one  of  the  most  eminent 
American  surgeons,  "  the  ligament  should  be  divided  without  any 
sawing  motion."^  It  is  evident  that,  if  the  cutting  edge  of  the  knife 
is  not  pushed  beyond  the  ligament  into  the  pelvis,  the  artery  will 
not  be  divided. 

I  have  noticed  that  the  obturator  vein  is  in  relation  to  the  femoral 
ring  in  a  much  larger  proportion  of  cases  than  the  artery,  it  being 
often  double,  one  going  to  the  internal  iliac,  the  other  to  the  exter- 
nal iliac  vein,  when  the  artery  was  from  the  anterior  trunk  of  the 
internal  iliac  alone. 

Deductions:  1st.  That  anatomists  giving  the  origin  of  the  obtu- 
rator artery  from  the  posterior  trunk  of  the  internal  iliac  are  positively 
wrong,  the  vessel  not  originating  from  this  point  in  more  than  10 
per  cent. 

2d.  That  in  females  it  will  be  derived  from  the  deep  epigastric  in 
on&  of  tiuo  or  two  and  one-half  cases. 

3d.  That  in  males  it  will  be  from  the  deep  epigastric  in  one  oifour 
or  six  cases, 

1  Hamilton's  System  of  Surgery,  p.  743. 


OBTURATOR    ARTKIiY.  201 

4th.  That  the  ohlurdlor  vein  i.s  found  to  empty  into  tin;  exlernal 
iliac  or  ejrtijasiric  vein  in  ;i  mueh  i/reater  [)roportion  of  crises  than 
the  artery  is  found  to  orignate  from  the  ej^idustric  or  exli-rnal  iliac. 

5th.  That  tlie  advice  to  "feel  for  the  pulsation  of  this  artery  be- 
fore cutting  Gimbernat's  ligament'"  (as  is  frequently  given),  seems 
unnecessary,  since  the  insertion  of  the  finger  through  the  constricted 
canal,  completely  filled  by  the  intestine,  ihxit  has  for  this  reason  he- 
come  strangulated,  is  impossible  until  after  the  section  is  made. 

6th.  That,  although  the  conditions  in  which  the  oltura.tor  artery 
is  found  to  the  inner  side  of  a  femoral  liernia  rarely  exist,  the  ope- 
ration should  be  niade  with  every  regard  to  this  abnormal  arrange- 
ment. 

Note. — In  one  instance  I  have  seen  the  obturator  a  bi'auch  of  the  epigfisiric,  and 
this  latter  a  branch  of  the  profunda  femoris.  This  specimen  is  the  property  of  the 
Wood  Museum  of  Bellevue  Hospital,  and  is  not  included  in  these  notes,  on  account 
of  its  being  so  unusual. 

■  Holmes's  Surgery,  vol.  iv.  p.  779. 


262  PRIZE     ESSAY. 

NOTES  ON  THE  SURGICAL  ANATOMY  OF  THE  HIP-JOINT/ 

The  comparatively  trifling  amount  of  blood  lost  in  an  operation 
of  such  magnitude  as  the  excision  of  the  hip-joint,  when  there  is  no 
means  of  stopping  the  supply  of  blood  to  the  part,  has  doubtless 
added  very  much  to  tlie  remarkable  success  which  has  attended  this 
operation  in  the  hands  of  its  author.  The  following  synopsis  of 
twenty  dissections  of  the  hip-joint  made  with  regard  to  the  arterial 
distribution  to  this  region,  may  serve  to  show  the  extreme  nicety 
of  execution  requisite,  in  order  to  avoid  hemorrhage,  that  would 
always  be  annoying,  and  in  some  instances  dangerous.  The  arteries 
found  distributing  branches  to  this  region  were  the  gluteal^  sciatic^ 
ohturator^  external  and  internal  circumflex^  and  the  superior  perforating 
by  anastomoses.  None  of  these  approached  the  line  of  incision 
given  by  Prof.  Say  re  near  enough  to  be  divided,  before  they  broke 
up  into  branches  of  distribution  too  small  to  give  rise  to  any  notice- 
able hemorrhage,  except  one  of  the  terminal  branches  of  the  internal 
circumflex,  sometimes  mentioned  as  the  trochanteric  branch,  but 
never  described  in  connection  with  the  surgical  anatomy  of  this  ope- 
ration, to  my  knowledge.  In  20  dissections  this  artery  was  present 
in  every  case.  In  18  of  these  it  came  from  the  internal  circumflex^ 
passed  between  thequadratus  femoris  behind,  and  the  obturator  ex- 
ternus  in  front,  and  turning  toward  the  digital  fossa,  broke  up  into 
its  terminal  branches  within  from  one-eighth  to  one-fourth  of  an  inch 
of  the  insertion  of  the  tendon  of  the  obturator  externus  into  that  fossa, 
anastomosing  with  the  sciatic^  gluteal^  and  external  circumflex  arteries. 
In  2  cases  in  which  it  failed  to  come  from  the  internal  circumfitx^  it 
was  derived  from  the  sciatic,  and  ran  in  the  depression  between  the 
quadratus  femoris  and  obturator  externus  muscles,  near  the  digital 
fossa. 

This  vessel  varied  in  size  from  a  crow's-quill,  down,  oftener  small 
than  large,  but  in  all  cases  of  sufl&cient  size,  at  the  distance  from  the 
fossa  above  given,  to  interfere  with  the  success  of  the  operation,  if 
carelessly  divided.  As  it  is  only  at  this  point  that  the  knife  is  used 
in  the  deeper  structures  (in  cutting  the  tendon  of  the  obturator  ex- 
ternus out  of  this  fossa),  it  behooves  the  surgeon  to  guard  against 
this  danger  by  keeping  the  point  of  the  knife  "well  against  the 
bone,"  as  advised  in  the  operation,  and  never  to  attempt  to  divide 
this  tendon  out  of  the  fossa.  (The  obturator  externus  muscle  was 
occasionally  observed  to  be  inserted  into  the  great  trochanter,  and 
not  into  the  digital  fossa.) 

1  From  Orthopedic  Surgery  and  Diseases  of  tlie  Joints.     By  Prof.  Lewis  A.  Sayke. 


COLUMBIA  UNIVFRSITY  LIBRARIES  (hsi.stx) 

RD14W97C.1 

Essays  in  surgical  anatomy  ant)  surgery 


2002097583 


l^P/4 


IVdl 


Wyeih  —    St^Tgica-l 


'■k^:.:":,.^.wa:^'.j:.ha^^.' 


